Inspection Reports for The Maples at Centennial
510 CENTENNIAL CIRCLE, NORTH PLATTE, NE, 69101
Back to Facility ProfileDeficiencies (last 12 years)
Deficiencies (over 12 years)
13.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
212% worse than Nebraska average
Nebraska average: 4.2 deficiencies/year
Deficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
68% occupied
Based on a June 2019 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Notice
Deficiencies: 0
Mar 18, 2025
Visit Reason
This Notice of Disciplinary Action was issued due to violations found related to the facility's failure to implement interventions to prevent weight loss in residents, as evidenced by the CMS-2567 Report dated March 18, 2025.
Findings
The facility was found to have violated licensure regulations concerning provision of care and treatment, specifically failing to implement interventions to prevent weight loss among residents. The license is placed on probation for 90 days starting April 15, 2025, with requirements to submit a Plan of Correction and ongoing reports.
Report Facts
Probation period days: 90
Date of CMS-2567 Report: Mar 18, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Timothy Tesmer | Chief Medical Officer | Signed the Notice of Disciplinary Action |
| Dan Taylor | RN, Administrator | Health Facilities Licensure Unit |
| Kolby Venger | Administrative Specialist | Office of Long Term Care Facilities |
Notice
Deficiencies: 0
Mar 18, 2025
Visit Reason
The notice was issued as disciplinary action against The Maples At Centennial nursing home for failure to implement interventions to prevent weight loss, based on findings from a survey dated March 18, 2025.
Findings
The facility failed to implement interventions to prevent weight loss among residents, violating licensure regulations related to provision of care and treatment and nutrition.
Report Facts
Probation period: 90
Date of survey: Mar 18, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Timothy Tesmer | Chief Medical Officer | Signed the Notice of Disciplinary Action. |
| Dan Taylor | Administrator | Health Facilities Licensure Unit contact named in the notice. |
| Kolby Venger | Administrative Specialist | Certified the Notice of Disciplinary Action copy. |
Notice
Capacity: 57
Deficiencies: 0
Mar 16, 2024
Visit Reason
This document serves as a renewal application for the assisted-living facility license of The Maples at Centennial and includes certification of occupancy and licensing renewal information.
Findings
The documents confirm that The Maples at Centennial meets statutory requirements as an assisted-living facility with a maximum occupancy of 57 beds and is licensed through the renewal date of 4/30/2025.
Report Facts
Total licensed beds: 57
Renewal license expiration date: 2025
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 24, 2020
Visit Reason
An unannounced visit was conducted to investigate a complaint at Centennial Park Retirement Village on February 24-25, 2020, 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 related regulatory requirements regarding pain management, timely submission of investigations, protection from residents with adverse behaviors, respect and dignity for residents, fall interventions, protection of narcotic medications, and ensuring staff were not under the influence of illegal drugs.
Complaint Details
The complaint allegations included failure to assist residents with pain management, failure to submit investigations in 5 working days, failure to protect residents from adverse behaviors, failure to ensure respect and dignity, failure to use fall interventions, failure to protect narcotic medication from diversion, and failure to ensure staff were not under the influence of illegal drugs. All allegations were found to be unsubstantiated with the facility in compliance.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Connie Vogt | Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed the report letter |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 29, 2020
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging the facility failed to give appropriate discharge notice.
Findings
The facility was found to have given appropriate discharge notices in a timely manner, with involvement of required staff groups, and was found to be in compliance with relevant regulations.
Complaint Details
The allegation was that the facility failed to give appropriate discharge notice. The investigation found the facility gave appropriate discharge notice and was in compliance.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Connie Vogt | Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed the inspection and complaint investigation reports. |
Inspection Report
Complaint Investigation
Census: 46
Capacity: 68
Deficiencies: 18
Jun 4, 2019
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Centennial Park Retirement Village on June 4, 2019-June 11, 2019, by representatives of the Department of Health and Human Services Division of Public Health.
Findings
The facility was cited for failure to include a resident's Power of Attorney in medication decisions, failure to notify the responsible party of medication changes, failure to implement a restorative nursing program as outlined in the care plan, failure to provide written notice of transfers to residents and representatives, failure to provide bed hold policy notices, failure to coordinate PASARR assessments, failure to implement care plan interventions, unsafe water temperatures, medication errors, infection control deficiencies, and fire and safety code violations.
Complaint Details
The complaint included allegations that the facility failed to follow the plan of care, failed to allow residents to exercise their rights, failed to notify the responsible party of changes in condition, failed to ensure sufficient staffing, and failed to provide services as identified in the plan of care. The investigation substantiated failures related to notification of responsible parties regarding medication changes and implementation of restorative nursing programs.
Severity Breakdown
SS=D: 9
SS=E: 5
SS=F: 3
Deficiencies (18)
| Description | Severity |
|---|---|
| Failure to include one sampled resident's Power of Attorney/Responsible Party in decisions related to the use or discontinuation of psychotropic medications. | SS=D |
| Failure to notify one sampled resident's Power of Attorney/Responsible Party of medication changes as they occurred. | SS=D |
| Failure to ensure one sampled resident's Restorative Nursing Program was implemented as outlined on the resident's individualized care plan. | SS=D |
| Failure to notify residents and legal representatives in writing of facility initiated transfers/discharges to hospital for 5 sampled residents. | SS=E |
| Failure to notify residents and legal representatives of the bed hold policy in writing within 24 hours of transfer/discharge to the hospital for 4 sampled residents. | SS=E |
| Failure to ensure a Level 2 PASARR had been requested after discovery of a newly evident diagnosis of a serious mental disorder for one resident. | SS=D |
| Failure to develop and implement a comprehensive care plan including measurable objectives and timeframes to meet resident's needs. | SS=D |
| Failure to maintain safe water temperatures in resident rooms and bathing tubs to prevent potential burn injury. | SS=E |
| Failure to provide pharmaceutical services to meet resident needs including medication availability, holding medications per parameters, and proper medication labeling. | SS=E |
| Failure to ensure residents are free of significant medication errors including administration of wrong insulin and failure to hold medications per vital sign parameters. | SS=E |
| Failure to ensure narcotic counts are immediately signed by staff at change of shift to verify accuracy. | SS=E |
| Failure to maintain resident records that are complete, accurately documented, readily accessible, and systematically organized including documentation of resident and representative concerns. | SS=D |
| Failure to establish and maintain an infection prevention and control program including hand hygiene during medication administration. | SS=E |
| Failure to provide an all-weather surface from each exit to a public way. | SS=F |
| Failure to maintain exit discharge lighting so that failure of one bulb would not leave the path in darkness. | SS=F |
| Failure to provide required safety features for cooking equipment including automatic shut off connection to hood fire extinguishing system and automatic ignition of burners. | SS=F |
| Failure to ensure corridor doors are provided with means suitable for keeping the door closed to resist passage of smoke. | SS=D |
| Use of power strip that did not meet UL standards in physical therapy room. | SS=D |
Report Facts
Facility census: 46
Total capacity: 68
Deficiencies cited: 17
Medication administration errors: 1
Elevated water temperatures: 12
Residents affected by bathing tub temperature: 18
Fire drills: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Beth Block | Administrator | Named as facility administrator in report |
| Connie Vogt | RN, BSN, Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed complaint investigation letter |
Inspection Report
Complaint Investigation
Deficiencies: 0
May 8, 2019
Visit Reason
An unannounced visit was conducted to investigate a complaint at Centennial Park Retirement Village, Ltd on May 8, 2019, regarding failure to notify practitioners of change in condition and failure to provide medications as ordered.
Findings
The facility was found to be in compliance with regulatory requirements for both allegations: practitioners were notified of changes in condition and medications were administered as ordered according to proper procedures.
Complaint Details
The complaint alleged failure to notify practitioners of change in condition and failure to provide medications as ordered. Both allegations were found to be unsubstantiated as the facility complied with related regulatory requirements.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Connie Vogt | Program Manager | Signed the complaint investigation report |
Inspection Report
Complaint Investigation
Census: 53
Deficiencies: 2
Feb 4, 2019
Visit Reason
An unannounced visit was conducted to investigate a complaint at Centennial Park Retirement Village on February 4-5, 2019, triggered by allegations including failure to submit investigations within 5 working days, failure to follow infection control guidelines, and failure to protect residents from injury.
Findings
The facility failed to submit an investigation report to the State Agency as required for one resident, resulting in a deficiency. The facility was found compliant with infection control guidelines overall, but a related deficiency was cited for failure to follow infection control procedures during injection administration for one resident. The facility was compliant with regulations regarding protection from injury.
Complaint Details
The complaint investigation was substantiated with findings of failure to submit investigation reports timely and failure to follow infection control procedures during injection administration. The facility was found compliant with other related allegations.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to submit investigations within 5 working days; investigation report not successfully transmitted to State Agency for one resident. | SS=D |
| Failure to follow infection control procedures to reduce risk of cross contamination during preparation and administration of an injection for one resident. | SS=D |
Report Facts
Facility census: 53
Sampled residents: 8
Closed records reviewed: 3
Sampled residents observed for medication administration: 4
Deficiency citation date: Feb 6, 2019
Deficiency citation date: Mar 1, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Connie Vogt | RN, BSN, Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed the complaint investigation letter. |
| LPN C | Licensed Practical Nurse | Observed administering insulin injection improperly, leading to infection control deficiency. |
| Director of Nursing | Interviewed confirming failure to submit investigation report and confirming nurses should follow infection control procedures. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jan 23, 2019
Visit Reason
An unannounced visit was conducted to investigate a complaint at Centennial Park Retirement Village, Ltd on January 23, 2019. The investigation included review of resident records, observation of care and services, and interviews with residents, family members, and staff.
Findings
The facility was found to be in compliance with regulatory requirements regarding resident condition stability, freedom from misappropriation, and accounting of resident funds. No deficiencies were identified related to the allegations.
Complaint Details
The complaint alleged the facility failed to ensure residents' conditions were stable and predictable, failed to ensure residents were free from misappropriation, and failed to account for resident funds to prevent misappropriation. All allegations were found to be unsubstantiated with the facility in compliance.
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
Sep 12, 2018
Visit Reason
An unannounced visit was conducted to investigate a complaint at Centennial Park Retirement Village on September 12, 2018, by representatives of the Department of Health and Human Services Division of Public Health.
Findings
The investigation found that the facility was in compliance with regulatory requirements regarding fall interventions and notification of adverse events after review of records and interviews with staff and residents.
Complaint Details
The complaint alleged that the facility failed to put fall interventions in place to prevent injuries and failed to notify appropriate parties of adverse events. Both allegations were investigated and found to be unsubstantiated with the facility in compliance.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator | Author of the report and representative of the Office of LTC Facilities - Licensure Unit - Division of Public Health |
Notice
Capacity: 57
Deficiencies: 0
Apr 30, 2018
Visit Reason
This document serves as a licensure renewal notice and application for the assisted-living facility Centennial Park Retirement Village, LTD, verifying the facility's license through the renewal date and providing renewal application details.
Findings
The document confirms that the facility meets statutory requirements for licensure as an assisted-living facility and includes ownership, business organization, and certification information. No inspection findings or deficiencies are reported.
Report Facts
Total licensed beds: 57
Maximum occupancy: 37
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Peggy Ratzlaff | Administrator | Named as facility administrator in the renewal application |
| Bruce J. Mackey Jr. | President & Chief Executive Officer | Named as officer of ownership entity Five Star Quality Care-NE, Inc. |
| R. Scott Herzig | Senior Vice President & Chief Operating Officer | Named as officer of ownership entity Five Star Quality Care-NE, Inc. |
| Richard A. Doyle | Treasurer & Chief Financial Officer | Named as officer of ownership entity Five Star Quality Care-NE, Inc. |
| Katherine E. Potter | Vice President, General Counsel & Assistant Secretary | Named as officer of ownership entity Five Star Quality Care-NE, Inc. |
| Jennifer B. Clark | Corporate Secretary | Named as officer of ownership entity Five Star Quality Care-NE, Inc. |
| Adam D. Portnoy | Director | Named as director of ownership entity Five Star Quality Care-NE, Inc. |
| Gerard M. Martin | Director | Named as director of ownership entity Five Star Quality Care-NE, Inc. |
Inspection Report
Annual Inspection
Census: 50
Capacity: 67
Deficiencies: 11
Apr 11, 2018
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Centennial Park Retirement Village from April 11, 2018 to April 17, 2018 by the Department of Health and Human Services Division of Public Health.
Findings
The facility was found in compliance with staffing requirements but failed to identify change in condition for some residents, had deficiencies in emergency preparedness plans, care planning, medication documentation, infection control, food service sanitation, and life safety code compliance including sprinkler system testing and corridor door smoke resistance.
Complaint Details
The complaint allegations were that the facility failed to ensure sufficient staffing and failed to identify change in condition. The allegation of insufficient staffing was not substantiated. The facility was cited for failure to identify change in condition and follow-up assessment.
Severity Breakdown
SS=C: 2
SS=D: 2
SS=E: 2
SS=F: 4
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to follow policies in identifying a possible injury/accident and following up with assessing the resident. | — |
| Failed to ensure the requirements for contact information for staff, resident physicians, volunteers, and emergency officials in the emergency preparedness plan. | SS=C |
| Failed to determine if changes in resident conditions required significant change MDS assessments for two residents. | SS=D |
| Failed to ensure a Nursing Assistant was included in the interdisciplinary team in the development, revision, and review of resident care plans for three residents. | SS=E |
| Failed to ensure the circumstances and condition of a resident found on the floor was assessed and documented following the incident. | SS=D |
| Failed to repair cracking, peeling paint and plaster from the ceiling and failed to clean dirt and debris on vents and ceiling in the main dining room. | SS=F |
| Failed to maintain complete and accurately documented medication disposition records for seven residents. | SS=E |
| Failed to ensure contaminated hands did not touch a clean dressing and failed to replace frayed safety straps on bathing chairs. | SS=F |
| Failed to maintain an effective pest control program; dead insects found inside light fixtures in the main kitchen. | SS=F |
| Failed to perform required quarterly tests of the fire sprinkler system; missing inspection in second quarter of 2017. | SS=F |
| Failed to provide corridor doors that resist the passage of smoke; door to room 510 did not completely close within the frame. | SS=E |
Report Facts
Residents sampled: 29
Facility census: 50
Total licensed capacity: 67
Deficiency count: 7
Number of residents affected by care plan deficiency: 3
Number of residents affected by significant change MDS deficiency: 2
Number of residents affected by fall assessment deficiency: 1
Number of residents affected by dressing change deficiency: 1
Number of residents affected by frayed bathing chair straps: 1
Number of light fixtures with dead insects: 2
Number of smoke zones affected by sprinkler deficiency: 3
Number of residents affected by corridor door deficiency: 14
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator | Signed complaint investigation letter |
| Cynthia Wheeler | Administrator | Facility administrator named in complaint investigation |
| RN-C | MDS Coordinator | Interviewed regarding MDS assessment deficiencies |
| RN-A | Registered Nurse | Observed performing contaminated dressing change |
| RN-B | Registered Nurse | Observed performing contaminated dressing change |
| RN-E | Registered Nurse | Involved in fall incident assessment failure |
| LPN-F | Licensed Practical Nurse | Witnessed fall incident |
| NA-D | Nurse Aide | Witnessed fall incident and assisted resident |
| NA-G | Nurse Aide | Reported fall incident |
| Maintenance A | Maintenance Supervisor | Interviewed regarding sprinkler system and corridor door deficiencies |
| Dietary Manager | Interviewed regarding food service sanitation and pest control deficiencies | |
| Administrator | Interviewed regarding multiple deficiencies including emergency preparedness and infection control |
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 27, 2018
Visit Reason
An unannounced visit was conducted to investigate a complaint at Centennial Park Retirement Village regarding allegations of failure to ensure residents' property is accounted for to prevent misappropriation and failure to protect residents from misappropriation.
Findings
The investigation found no missing items or concerns related to misappropriation after resident interviews, record reviews, and policy assessments. The facility followed policies and procedures appropriately, and no violations were found.
Complaint Details
The complaint alleged failure to account for residents' property and failure to protect residents from misappropriation. The investigation found no violations and no substantiated concerns.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator | Signed the report and identified as representative of the Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 27, 2017
Visit Reason
An unannounced visit was conducted to investigate a complaint at Centennial Park Retirement Village on July 27, 2017, focusing on allegations related to appropriate positioning/transfers, resident injury protection, evaluation of fall causal factors, and timely submission of investigations.
Findings
The investigation found the facility in compliance with all related regulatory requirements for the allegations investigated, including appropriate positioning/transfers, protection from injury, evaluation of fall causal factors, and submission of investigations within 5 working days.
Complaint Details
The complaint included four allegations: failure to provide services for appropriate positioning/transfers, failure to protect residents from injury, failure to evaluate causal factors for falls, and failure to submit investigations within 5 working days. All allegations were found to be unsubstantiated with the facility in compliance.
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 |
| Peggy Ratzlaff | Administrator | Facility Administrator interviewed regarding submission of investigations |
Inspection Report
Complaint Investigation
Census: 43
Deficiencies: 1
Apr 18, 2017
Visit Reason
An unannounced visit was conducted to investigate a complaint at Centennial Park Retirement Village on April 18, 2017, focusing on multiple allegations including failure to give appropriate discharge notice, failure to report falls with injury, and other care-related concerns.
Findings
The facility was found to be in compliance with most allegations except for failure to report a resident's fall with injury to the State Agency, which was determined to be a violation of federal and state regulations.
Complaint Details
The complaint investigation substantiated that the facility failed to report a fall with injury involving Resident 42 to the State Agency. The fall occurred on 3/13/2017, and the resident was sent to the hospital, but the incident was not reported as required. The facility census was 43 at the time.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report a resident's fall with injury to the State Agency. | SS=D |
Report Facts
Facility census: 43
Sampled residents: 3
Affected residents: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed the complaint investigation report |
| Tina Muller | Administrator | Facility administrator addressed in the report |
Inspection Report
Complaint Investigation
Deficiencies: 0
Feb 23, 2017
Visit Reason
An unannounced visit was conducted to investigate a complaint regarding the facility's housekeeping program and injury prevention interventions at Centennial Park Retirement Village.
Findings
The facility was found to be in compliance with related regulatory requirements for both maintaining an effective housekeeping program and putting interventions into place to prevent injuries.
Complaint Details
The complaint alleged that the facility failed to maintain an effective housekeeping program and failed to put interventions into place to prevent injuries. Both allegations were investigated and found to be unsubstantiated as the facility was in compliance.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator, Licensure Unit, Division of Public Health-DHHS | Signed the complaint investigation report |
Notice
Deficiencies: 0
Feb 13, 2017
Visit Reason
The notice was issued to impose disciplinary action placing the facility's license on probation for 90 days starting February 28, 2017, due to violations of licensure regulations related to provision of care and special needs, including failure to assess and provide interventions for pain and respiratory monitoring.
Findings
The facility was found in violation of multiple licensure regulations, including failure to assess residents' pain and respiratory status and to provide appropriate interventions, resulting in probationary status with required submission of plans of correction and periodic reports.
Report Facts
Probation period: 90
Report due date: Mar 10, 2017
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | RNC, Program Manager | Recipient of required reports and contact for the Notice of Disciplinary Action |
| Thomas L. Williams | Chief Medical Officer, Director, Division of Public Health | Signed the Notice of Disciplinary Action |
| Becky Wisell | Administrator, Licensure Unit | Signed the Notice of Disciplinary Action |
| Linda Stenvers | Staff Assistant II, Office of Long Term Care Facilities | Certified service of the Notice of Disciplinary Action |
| Peggy Ratzlaff | Administrator | Facility administrator addressed in the August 18, 2017 letter terminating probation |
Inspection Report
Annual Inspection
Census: 50
Capacity: 68
Deficiencies: 23
Jan 30, 2017
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Centennial Park Retirement Village on January 23, 2017-January 26, 2017, by representatives of the Department of Health and Human Services Division of Public Health.
Findings
The facility was cited for multiple deficiencies including failure to ensure sufficient staffing, prompt response to calls for assistance, meals being attractive and palatable, care and treatment for bladder elimination, privacy during personal cares, pain management, comprehensive assessments, care plan development, medication administration errors, infection control, call light functionality, and fire safety code violations.
Severity Breakdown
Level E: 9
Level D: 5
Level G: 2
Level F: 6
Deficiencies (23)
| Description | Severity |
|---|---|
| Failed to ensure privacy was provided during personal cares to prevent exposure of residents' bodies for three sampled residents. | Level E |
| Failed to assess, provide cares and follow up with complaints of pain related to an ongoing sore throat and earache for one sampled resident. | Level G |
| Failed to ensure oral care was offered for one sampled resident dependent on staff for assistance. | Level D |
| Failed to ensure care was provided to manage urinary incontinence for two sampled residents dependent on staff for assistance. | Level D |
| Failed to assess finger contractures and provide care to maintain function or prevent further loss of function for one sampled resident. | Level D |
| Failed to ensure oxygen was in place and administered as ordered and respiratory status was monitored for one sampled resident who frequently removed oxygen. | Level G |
| Failed to administer scheduled aerosol medication and antidepressant medication for two sampled residents resulting in medication errors. | Level D |
| Failed to ensure sufficient nursing staff to meet resident needs for toileting, meal delivery and assistance, and timely response to call lights. | Level D |
| Failed to ensure refrigerated desserts were not served until residents were present in the dining room and food was served at palatable temperatures. | Level E |
| Failed to ensure food was procured, stored, prepared and served in a sanitary manner including labeling of sugar and flour containers, monitoring refrigerator and freezer temperatures, proper hair restraints, and proper use of disposable gloves. | Level F |
| Failed to offer routine dental services for one sampled resident with missing and broken teeth. | Level D |
| Failed to ensure infection control protocols were followed including replacement of contaminated oxygen cannula, cleaning and covering respiratory equipment, proper storage of personal care items, and proper handling of soiled bedpans and catheter drainage bags. | Level E |
| Failed to ensure bathroom call lights were functional in rooms occupied by three sampled residents. | Level E |
| Failed to maintain complete, accurate, and accessible medical records including medication administration and treatment documentation for four sampled residents. | Level E |
| Failed to maintain a quality assessment and assurance committee that re-evaluates prior plans of correction and implements plans to correct quality deficiencies. | Level F |
| Failed to maintain an egress pathway free of obstructions creating a trip hazard that could delay evacuation or cause injury during an emergency evacuation. | Level E |
| Failed to maintain delayed egress door that did not release upon application of force and did not sound an alarm. | Level F |
| Failed to maintain exit discharge pathway free of obstructions as snow was present on the sidewalk outside an emergency exit. | Level E |
| Failed to maintain smoke resistant partitions in the boiler room allowing fire and smoke to spread through common spaces. | Level E |
| Failed to perform required quarterly tests of the fire sprinkler water flow alarm. | Level F |
| Failed to conduct all fire drills under varying conditions for the past year and failed to conduct fire drills quarterly for each shift. | Level F |
| Failed to document weekly generator inspections for three of fifty-two weeks of the past year. | Level F |
| Failed to maintain 36 inch clearance between electrical service panels and combustible materials outside of the oxygen storage room. | Level E |
Report Facts
Facility census: 50
Sample size: 17
Medication error rate: 8
Number of beds: 68
Number of residents affected by egress obstruction: 15
Number of residents affected by snow obstruction: 20
Number of weeks missing generator inspections: 3
Number of quarterly sprinkler tests missed: 2
Number of fire drills missed: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tina Muller | Administrator | Named in cover letter and correspondence |
| Eve Lewis | Program Manager | Signed cover letter and correspondence |
| Kimberly A. Divis | RN, NSSC | Reviewer for Informal Dispute Resolution |
| Maintenance A | Maintenance Staff | Interviewed regarding egress obstruction, sprinkler testing, fire drills, electrical clearance |
| LPN-T | Licensed Practical Nurse | Observed medication administration and medication omission |
| LPN-H | Licensed Practical Nurse | Charge nurse, interviewed regarding medication administration and oxygen use |
| NA-B | Nursing Assistant | Interviewed regarding incontinence care |
| NA-M | Nursing Assistant | Interviewed regarding oxygen use and incontinence care |
| MA-E | Medication Aide | Observed and interviewed regarding oral care and incontinence care |
| DA-U | Dietary Aide | Interviewed regarding food service and temperatures |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple care and compliance issues |
Inspection Report
Complaint Investigation
Deficiencies: 0
Oct 11, 2016
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging the facility fails to protect residents from abuse.
Findings
The investigation found no issues of abuse among sampled residents. Records, observations, and interviews indicated all identified issues had been resolved and no violations related to abuse were noted.
Complaint Details
The complaint alleged failure to protect residents from abuse. The investigation was substantiated with no violations found; all issues were resolved to residents' satisfaction.
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
Census: 73
Capacity: 75
Deficiencies: 9
Mar 22, 2016
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Good Shepherd Lutheran Home from March 16, 2016 to March 22, 2016 by the Department of Health and Human Services Division of Public Health.
Findings
The facility was found to be in compliance with the complaint allegation regarding protection from residents with behaviors. However, deficiencies were cited related to failure to maintain proper wheelchair positioning for Resident 58, life safety code violations including fire door maintenance, emergency lighting, fire drills, fire alarm system documentation, sprinkler head clearance, emergency generator remote stop, and oxygen use signage.
Complaint Details
The complaint allegation was that the facility failed to protect residents from residents with behaviors. The investigation found no violation related to this allegation as staff used excellent calming and intervention techniques and the facility was in compliance.
Severity Breakdown
SS=D: 1
SS=E: 4
SS=F: 4
Deficiencies (9)
| Description | Severity |
|---|---|
| Facility staff failed to identify and provide services to maintain or improve upright body alignment for Resident 58 who leaned to the right in wheelchair without positioning devices. | SS=D |
| Failed to maintain door to hazardous area (300/400 Hall Supply Room) to latch within door frame and failed to provide smoke resisting partitions in two hazardous areas. | SS=E |
| Physical Therapy egress door dragged on frame requiring excessive force; 500/600 hall sliding power door had power off and emergency breakaway failed to open. | SS=E |
| Emergency lighting failed to operate properly at generator and transfer switch areas. | SS=F |
| Fire drills were not held at random times under varied conditions for four of five quarters reviewed. | SS=F |
| Incomplete documentation for annual fire alarm system inspection as required by NFPA 72. | SS=F |
| Failed to maintain sprinkler heads in accordance with listing and failed to ensure upright sprinkler heads were installed within required clearance range. | SS=E |
| Failed to provide a remote manual stop for the emergency generator. | SS=F |
| Failed to post precautionary oxygen use signs on doors where oxygen was administered. | SS=E |
Report Facts
Facility census: 73
Total capacity: 75
Deficiency count: 9
Fire drills: 4
Fire drills: 4
Sprinkler clearance: 18
Sprinkler clearance observed: 4
Sprinkler head distance: 16
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed complaint investigation letter |
| Tina Muller | Administrator | Named in correspondence related to Informal Dispute Resolution |
| Maintenance A | Interviewed and verified multiple facility maintenance findings | |
| NA B | Nurse Aide | Interviewed regarding Resident 58's wheelchair positioning |
| NA C | Nurse Aide | Interviewed regarding Resident 58's wheelchair positioning |
| Director of Nursing (DON) | Interviewed regarding Resident 58's wheelchair positioning and therapy services | |
| Occupational Therapist (OT) | Interviewed regarding Resident 58's wheelchair positioning and therapy services |
Inspection Report
Complaint Investigation
Census: 45
Deficiencies: 0
Nov 17, 2015
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging that the facility fails to allow residents visitors as the resident desires.
Findings
The investigation found that residents could have visitors at any time without restrictions, and no concerns regarding visitor restrictions were identified from resident interviews, family interviews, facility policies, or grievance records. The facility was not cited for deficient practice.
Complaint Details
The allegation was that the facility fails to allow residents visitors as the resident desires. The allegation was not substantiated based on interviews and record reviews.
Report Facts
Facility census: 45
Residents sampled: 4
Residents interviewed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator, Licensure Unit, Division of Public Health-DHHS | Author of the inspection report |
Inspection Report
Annual Inspection
Census: 35
Deficiencies: 24
Nov 4, 2015
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Centennial Park Retirement Village on November 1, 2015-November 4, 2015, by representatives of the Department of Health and Human Services Division of Public Health.
Findings
The survey included investigations of multiple allegations including abuse, staffing, alcohol use, call light reach, food form, housekeeping, medication labeling, privacy, dignity, room change notice, social services, housekeeping, care planning, catheter care, accident hazards, immunizations, food consistency, sanitation, pharmaceutical services, infection control, call light system, ventilation, record keeping, fire safety, and emergency preparedness. Several deficiencies were cited and plans of correction were provided.
Complaint Details
The inspection included a complaint investigation regarding allegations of abuse, staffing, alcohol use, call light reach, food form, and housekeeping. No violations were found for abuse, staffing, alcohol use, call light reach, food form, or housekeeping due to lack of evidence or sufficient corrective actions.
Severity Breakdown
SS=F: 6
SS=E: 7
SS=D: 8
: 1
Deficiencies (24)
| Description | Severity |
|---|---|
| Failed to label the contents of and include expiration dates for medications stored in a narcotic/psychotropic emergency drug box. | — |
| Failed to ensure medication administration record notebooks were closed when unattended, privacy during injections and vital signs. | SS=E |
| Failed to maintain resident dignity by allowing ambulation in nightclothes. | SS=D |
| Failed to provide notice before room change for one resident. | SS=D |
| Failed to provide medically-related social services after resident refused bathing for more than 1 month. | SS=D |
| Failed to maintain sanitary housekeeping and maintenance including repair of walls, flooring, and cleanliness of bed tables and wheelchairs. | SS=E |
| Failed to develop comprehensive care plan including dialysis access cares for one resident. | SS=D |
| Failed to ensure resident care plan updated to include change in liquid consistency for one resident. | SS=D |
| Failed to provide dialysis cares and monitoring and failed to identify and investigate bruises for residents on dialysis. | SS=E |
| Failed to provide ADL care including bathing and changing soiled clothing for dependent residents. | SS=E |
| Failed to ensure written plan to restore bladder function, provide urinary catheter cares and monitoring, and update bladder assessment for one resident with urinary catheter. | SS=D |
| Failed to assess bed rail for safety hazards and ensure oxygen concentrators were turned off when not in use. | SS=E |
| Failed to ensure residents received requested pneumococcal vaccination. | SS=D |
| Failed to ensure correct consistency liquids were delivered to one resident on nectar consistency diet. | SS=D |
| Failed to store bowls to prevent dust accumulation and maintain clean shelving and oven in kitchen. | SS=F |
| Failed to obtain after-hours emergency pain medication for one resident resulting in transfer to emergency room. | SS=D |
| Failed to ensure disposable gloves were worn when administering injections and handwashing performed after glove removal. | SS=E |
| Failed to ensure call light was sounding for one resident due to pinched cord under bed frame. | SS=D |
| Failed to ensure bathroom ventilation was working in two resident rooms. | SS=D |
| Failed to maintain complete, accurate, and accessible clinical records including documentation of insulin administration, blood sugar testing, and blood pressure monitoring. | SS=D |
| Failed to conduct fire drills at varying times and conditions and maintain fire alarm activity log. | SS=F |
| Failed to test and inspect fire alarm system every 6 months. | SS=F |
| Failed to perform monthly portable fire extinguisher inspections for all months. | SS=F |
| Failed to perform weekly generator inspections and document engine hours. | SS=F |
Report Facts
Facility census: 35
Deficiency counts: 22
Fire drills times: 5
Missed fire extinguisher inspections: 1
Missed generator inspections: 3
Dialysis frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator | Signed cover letter for inspection report |
| Tina Muller | Administrator | Facility administrator named in report |
| LPN-H | Licensed Practical Nurse | Observed cutting lock on emergency drug box |
| LPN-B | Licensed Practical Nurse | Administered insulin injection without gloves |
| LPN-F | Licensed Practical Nurse | Administered insulin injection without gloves |
| LPN-C | Licensed Practical Nurse | Provided information on dialysis and catheter care |
| RN-D | Registered Nurse | Provided information on dialysis and emergency drug box |
| SWN | Skin and Wound Nurse | Verified bruises and skin assessments |
| Social Service Director | Interviewed regarding social service support and room changes | |
| Speech Therapist | Provided orders for diet consistency changes | |
| Maintenance Supervisor | Interviewed regarding fire safety and maintenance issues | |
| Dietary Manager | Interviewed regarding kitchen sanitation | |
| Corporate Nurse Consultant | Interviewed regarding emergency drug box and bruising | |
| Administrator | Interviewed regarding multiple deficiencies and corrective actions |
Notice
Deficiencies: 0
Sep 29, 2015
Visit Reason
This Notice of Disciplinary Action was issued due to the facility's failure to notify the physician of significant changes in two residents' medical conditions, resulting in disciplinary action and probation of the facility's license for one year starting October 14, 2015.
Findings
The facility violated licensure regulations related to Charge Nurse Requirements and failed to notify physicians of significant changes in residents' conditions, leading to probation and requirements for submitting plans of correction and periodic reports during the probation period.
Report Facts
Probation period length: 1
First report due date: 2015
License number: 514001
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | RNC, Program Manager | Recipient of reports and contact for response regarding disciplinary action |
| Courtney N. Phillips | Chief Executive Officer | Signed the Notice of Disciplinary Action |
| Becky Wisell | Administrator | Signed the Notice of Disciplinary Action |
Inspection Report
Complaint Investigation
Deficiencies: 0
Sep 15, 2015
Visit Reason
An unannounced visit was conducted to investigate a complaint that the facility fails to provide services as agreed upon in the service agreement.
Findings
The facility was found to provide services as agreed upon in the service agreement. Interviews with residents and staff, as well as review of grievance files and resident council meeting minutes, revealed no concerns and no deficiencies were cited.
Complaint Details
The complaint alleged failure to provide services as agreed upon in the service agreement. The complaint was not substantiated as the investigation found no deficiencies.
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
Census: 43
Deficiencies: 2
Sep 2, 2015
Visit Reason
A partial survey was conducted to determine compliance with Medicare and Medicaid requirements and Skilled Nursing Facility regulations, triggered by concerns about failure to notify physicians of significant changes in residents' conditions.
Findings
The facility failed to notify the physician of significant changes in condition for two residents, including elevated blood sugar and symptoms in Resident 1, and hypoactive bowel sounds and refusal of medications in Resident 4, constituting an immediate threat to resident health and safety.
Complaint Details
The complaint investigation found substantiated immediate jeopardy due to failure to notify physicians of significant changes in residents' conditions. Immediate jeopardy was abated after re-education and staff changes, with severity lowered to level D.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to notify the physician of Resident 1's complaints of shakiness, sweating, choking, and elevated blood sugar, and failure to act on these symptoms. | SS=D |
| Failure to notify the physician of Resident 4's hypoactive bowel sounds, refusal of medications, agitation, and lack of bowel movements for 9 days. | SS=D |
Report Facts
Civil Monetary Penalty: 5000
Facility census: 43
Blood sugar level: 319
Days without bowel movement: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | Program Manager - Office of LTC Facilities - Licensure Unit | Signed preliminary determination letter |
| Kathy Gibbons | Social Worker | Conducted partial survey |
| Keeli Klein | Registered Nurse | Conducted partial survey |
| Kaylene Straetker | Registered Nurse | Conducted partial survey |
| Unnamed Director of Nursing | Director of Nursing | Interviewed regarding failure to notify physician |
Inspection Report
Renewal
Census: 39
Deficiencies: 3
Aug 25, 2015
Visit Reason
The inspection was a licensure compliance inspection conducted to assess the facility's adherence to licensure regulations for Assisted-Living Facilities, including medication administration and building maintenance.
Findings
The facility was found noncompliant with medication administration policies, specifically regarding the administration timing and labeling of eye drops for a resident, and with building maintenance issues including ceiling repair and cleanliness of lighting fixtures.
Deficiencies (3)
| Description |
|---|
| Failure to ensure eye drops were administered at least 5 minutes apart and medication labels matched physician orders. |
| Ceiling in the 300 and main hallways was peeling and needed repair. |
| Overhead lighting fixtures in the 300, 400, and main hallways contained dead insects and debris. |
Report Facts
Facility census: 39
Estimated time to correct medication administration violation: Oct 12, 2015
Estimated time to correct ceiling repair violation: Oct 16, 2015
Estimated time to correct lighting fixture cleanliness violation: Aug 26, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Keeli Klein | Registered Nurse | Surveyor who conducted the inspection |
| Saza Lee | Administrator | Facility administrator involved in interviews |
| Resident Service Director | Resident Service Director | Responsible for corrective actions related to medication administration |
| Director of Maintenance | Director of Maintenance | Responsible for corrective actions related to building repairs and lighting fixture cleaning |
Inspection Report
Complaint Investigation
Census: 39
Deficiencies: 2
Aug 18, 2015
Visit Reason
An unannounced visit was conducted to investigate a complaint regarding failure to prevent pressure ulcers at Centennial Park Retirement Village.
Findings
The facility was found to have failed to prevent pressure ulcers from occurring, with two residents developing facility-acquired pressure ulcers. Other allegations regarding dehydration and incontinent care were not substantiated. Additionally, a separate finding noted improper removal of used pain patches during medication administration.
Complaint Details
The complaint investigation was triggered by an allegation that the facility failed to prevent pressure ulcers. The investigation confirmed two residents developed facility-acquired pressure ulcers. Other allegations about dehydration and incontinent care were not substantiated.
Deficiencies (2)
| Description |
|---|
| Failure to prevent pressure ulcers from occurring. |
| Failure to remove used pain patches before applying new patches per nursing standards. |
Report Facts
Facility census: 39
Deficiency citation: 1
Date of complaint report: Aug 10, 2015
Survey date: Aug 19, 2015
Estimated correction completion date: Sep 23, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kaylene Straetker | Registered Nurse | Surveyor conducting complaint investigation |
| Elizabeth Cook | Residential Service Director, RN | Responsible for corrective action and training related to pain patch application |
| Eve Lewis | Program Manager - Office of LTC Facilities - Licensure Unit | Author of complaint investigation letter |
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 1
Aug 18, 2015
Visit Reason
An unannounced visit was conducted to investigate a complaint regarding the facility's failure to prevent pressure ulcers from occurring.
Findings
The facility failed to prevent pressure ulcers from occurring in two sampled residents, confirmed by record reviews and staff interviews. Other allegations regarding dehydration and incontinent care were found to be unfounded with no deficiencies cited.
Complaint Details
The complaint alleged failure to prevent pressure ulcers, failure to ensure residents were not dehydrated, and failure to assist residents with incontinent care. Only the pressure ulcer allegation was substantiated with a deficiency cited.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to identify and provide interventions to prevent the development of pressure ulcers for two residents. | SS=D |
Report Facts
Facility census: 49
Residents reviewed for pressure ulcers: 3
Residents reviewed for dehydration and incontinent care: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kaylene Straetker | Registered Nurse | Conducted the complaint investigation visit |
| Eve Lewis | Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed the letter regarding the complaint investigation findings |
| Saza Lee | Administrator | Facility administrator addressed in the report |
| Director of Nursing | DON | Interviewed during the investigation confirming high risk residents and lack of interventions |
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 4
Jul 20, 2015
Visit Reason
An unannounced visit was conducted to investigate a complaint survey at Centennial Park Retirement Village on July 20-21, 2015, regarding allegations of insufficient staffing, failure to provide services as identified in the plan of care, use of restraints, personal property accounting, weight loss management, and nutritional intake.
Findings
The investigation confirmed deficiencies related to insufficient staffing to meet residents' needs and failure to provide services as identified in care plans. No deficiencies were found regarding restraint use, personal property accounting, weight loss, or nutritional intake. Additional deficiencies included failure to complete discharge summaries, inadequate fall prevention interventions, and insufficient nursing staff to meet resident needs.
Complaint Details
The complaint investigation was triggered by allegations that the facility failed to have sufficient staff to meet residents' needs, failed to provide services as identified in the plan of care, failed to ensure restraints were not used, failed to ensure personal property was accounted for, failed to address significant weight loss, and failed to provide adequate intake of calories or nutrients. The investigation substantiated staffing and care plan service deficiencies but found no issues with restraints, personal property, weight loss, or nutrition.
Severity Breakdown
SS=F: 1
SS=E: 1
SS=D: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Facility failed to have sufficient staff to meet residents' needs. | SS=F |
| Facility failed to provide services as identified in the plan of care related to assistance with activities of daily living for four sampled residents. | SS=E |
| Facility failed to complete discharge summaries for three sampled closed records. | SS=D |
| Facility failed to identify causal factors and implement interventions to reduce risk for recurrent falls for one current and one closed resident. | SS=D |
Report Facts
Facility census: 54
Residents sampled for care plan deficiency: 4
Residents sampled for discharge summary deficiency: 3
Residents sampled for fall prevention deficiency: 2
Deficiency citations: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kaylene Straetker | Registered Nurse | Conducted the complaint investigation survey |
| Eve Lewis | Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed the complaint investigation letter |
| Director of Nursing | Confirmed staffing issues and care plan deficiencies during interviews | |
| Assistant Director of Nursing | Scheduled nursing staff and confirmed staffing shortages | |
| Social Services Director | Confirmed discharge summaries were not completed for sampled closed records | |
| Administrator | Confirmed discharge summaries were required for all discharged residents |
Inspection Report
Complaint Investigation
Census: 52
Deficiencies: 1
Jun 8, 2015
Visit Reason
An unannounced visit was conducted to investigate complaints regarding the facility's response to call notification systems, treatment of residents with respect and dignity, use of fall interventions, and timely submission of investigation reports.
Findings
The investigation found no violations related to call system response, resident dignity, or fall prevention interventions. However, the facility failed to submit investigation findings to the State Agency within the required five working days for incidents involving two residents, resulting in a deficiency citation.
Complaint Details
The complaint investigation included allegations that the facility failed to answer call notification systems promptly, failed to ensure residents were treated with respect and dignity, failed to use fall interventions to prevent injuries, and failed to send investigation reports within five working days. The first three allegations were not substantiated; the last was substantiated.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide the State Agency with investigation findings within five working days for incidents involving two residents. | SS=D |
Report Facts
Facility census: 52
Number of residents sampled: 6
Number of residents interviewed: 3
Number of family members interviewed: 1
Number of incidents not reported timely: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Schumacher | Registered Nurse | Conducted the complaint investigation |
| Eve Lewis | Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed the complaint investigation letter |
| Saza Lee | Administrator | Facility administrator addressed in the report |
| Interim Director of Nursing | IDON | Interviewed regarding failure to submit investigations timely |
Inspection Report
Annual Inspection
Census: 51
Capacity: 68
Deficiencies: 15
Oct 9, 2014
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Centennial Park Retirement Village on October 6-9, 2014.
Findings
The facility was found to have no violations related to narcotic medication misappropriation and fall prevention. Deficiencies were identified in dignity and respect related to mechanical lift slings, housekeeping and maintenance issues, assessment accuracy, care planning, discharge summaries, medication administration, infection control, and life safety code compliance including sprinkler system coverage and generator testing.
Complaint Details
The complaint investigation included allegations of narcotic medication misappropriation and failure to protect residents from falls. The facility was found to have policies and procedures in place for narcotic medications and no violations were identified. The facility was identifying residents at risk for falls and implementing interventions. No violations were found related to falls.
Severity Breakdown
Level B: 1
Level D: 8
Level E: 4
Level F: 1
Deficiencies (15)
| Description | Severity |
|---|---|
| Failed to ensure mechanical lift transfer slings were removed from wheelchairs to promote dignity for two residents. | Level D |
| Failed to maintain housekeeping and maintenance services including soiled bathroom call light strings, unclean bathroom vents, damaged walls, adhesive on floors, and damaged bathroom door guards. | Level E |
| Failed to identify one resident as receiving dialysis during MDS assessment reviews. | Level D |
| Failed to develop a comprehensive care plan for one resident addressing chronic insomnia and routine use of hypnotic medication. | Level D |
| Failed to update care plans for residents to monitor abdominal girth, safe transfer equipment, and behavioral management. | Level D |
| Failed to complete discharge summaries recapitulating residents' stays for five sampled residents. | Level B |
| Failed to monitor abdominal girth as ordered for ongoing assessment of constipation for one resident. | Level D |
| Failed to ensure oxygen concentrators were turned off when not in use for five residents. | Level E |
| Failed to monitor effectiveness of hypnotic medication for one resident with chronic sleep disorder. | Level D |
| Failed to administer medication as directed by physician orders for one resident. | Level D |
| Failed to dispose of six out-dated suppositories for one resident. | Level D |
| Failed to provide an environment to prevent potential cross contamination including unlabeled towels, soiled call light cords, unclean respiratory equipment, undated distilled water and saline solution, and soiled cloths in resident bathrooms. | Level E |
| Failed to install a complete coverage sprinkler system for the building, leaving 24 residents at greater risk of fire damage. | Level E |
| Failed to document monthly generator load tests for two months of the past year. | Level F |
| Failed to maintain electrical wiring in accordance with National Electric Code as exposed wires were found outside under a south eave. | Level D |
Report Facts
Facility census: 51
Total capacity: 68
Residents affected by sprinkler deficiency: 24
Residents sampled for infection control issues: 8
Residents sampled for soiled call light cords: 6
Residents sampled for unclean respiratory equipment: 2
Residents sampled for undated distilled water: 1
Residents sampled for undated saline solution: 1
Residents sampled for soiled cloths in bathroom: 1
Months missing generator load test documentation: 2
Residents sampled for oxygen concentrator left on: 5
Residents sampled for discharge summary deficiency: 5
Inspection Report
Complaint Investigation
Deficiencies: 0
Jun 3, 2014
Visit Reason
An unannounced visit was conducted to investigate a complaint at Centennial Park Retirement Village on June 3-4, 2014, regarding multiple allegations about resident care and facility operations.
Findings
Each allegation was investigated through record reviews, observations, and interviews. The facility was found to be in compliance with related regulatory requirements for all allegations, including staffing sufficiency, resident hygiene, call system responsiveness, bowel elimination care, meal quality, and mechanical lift use.
Complaint Details
The investigation addressed multiple allegations including insufficient staffing, failure to ensure clean hair, skin and teeth, delayed call notification response, inadequate bowel elimination care, poor meal quality and nutrition, and improper use of mechanical lifts. All allegations were found to be unsubstantiated with the facility in compliance.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Betty Smith | Registered Nurse | Conducted the complaint investigation. |
| Michelle Hochstetler | Administrator | Facility administrator addressed in the report. |
| Eve Lewis | Program Manager | Signed the report as Program Manager, Office of Long Term Care Facilities. |
Inspection Report
Annual Inspection
Census: 50
Capacity: 68
Deficiencies: 14
Jul 31, 2013
Visit Reason
Annual survey to assess compliance with state and federal regulations including resident care, safety, and facility maintenance.
Findings
The facility was found deficient in multiple areas including resident record maintenance, notification of changes in condition, life safety code compliance, medication administration, nutrition and hydration, skin and wound care, fall prevention, grievance resolution, and quality assurance processes.
Severity Breakdown
SS=E: 9
SS=D: 3
SS=G: 1
Deficiencies (14)
| Description | Severity |
|---|---|
| Failed to ensure 2 residents' personal inventory records were updated. | — |
| Failed to notify physicians of changes in condition related to elevated blood sugars and significant weight loss for residents. | SS=D |
| Failed to resolve and provide follow-up on grievances for a resident. | SS=D |
| Failed to maintain a sanitary, orderly, and comfortable interior including marred walls, gouges, stained tile, and non-cleanable wheelchair parts. | SS=E |
| Failed to conduct comprehensive, accurate, standardized assessments of residents' functional capacity including toileting needs and weight loss prevention. | SS=E |
| Failed to develop comprehensive care plans addressing end of life wishes and behavioral management for residents. | — |
| Failed to meet professional standards by following physician orders in insulin administration for residents. | SS=E |
| Failed to provide care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being including fluid restriction assessment and skin condition monitoring. | SS=E |
| Failed to ensure resident environment was free of accident hazards including unsecured chemicals and inadequate fall prevention interventions. | SS=E |
| Medication error rate of 11% due to insulin administration errors for 3 residents. | SS=E |
| Failed to follow preplanned menus for service of milk or milk substitutes affecting 37 residents. | SS=E |
| Failed to maintain an effective Quality Assurance Program including quarterly meetings, physician attendance, and corrective action implementation. | SS=G |
| Failed to maintain acceptable clearance to prevent obstructions to sprinkler spray patterns. | SS=E |
| Failed to secure oxygen tanks to prevent accidental damage or dislocation. | SS=E |
Report Facts
Facility capacity: 68
Facility census: 50
Medication administration errors: 13
Medication error rate: 11
Weight loss percentage: 24
Weight loss percentage: 18.9
Weight loss percentage: 8.8
Weight loss percentage: 2.6
Fluid intake limit: 1200
Residents affected by environmental issues: 13
Residents affected by unsecured chemicals: 7
QA committee meetings: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN-M | Registered Nurse | Involved in insulin administration errors and medication observations. |
| LPN-D | Licensed Practical Nurse | Administered insulin and confirmed blood sugar readings. |
| DON | Director of Nursing | Provided multiple interviews regarding care plans, fall prevention, medication errors, and quality assurance. |
| SSD | Social Service Director | Interviewed regarding grievance follow-up, end of life care, and care planning. |
| DM | Dietary Manager | Interviewed regarding meal service and dietary documentation. |
| Dietary Tech | Dietary Technician | Interviewed regarding meal documentation and dietary preferences. |
| Maintenance Staff A | Maintenance Staff | Confirmed sprinkler and oxygen tank observations. |
| Administrator | Facility Administrator | Interviewed regarding QA committee and grievance processes. |
Inspection Report
Complaint Investigation
Census: 47
Deficiencies: 1
Nov 15, 2012
Visit Reason
The inspection was conducted as a complaint investigation regarding the facility's failure to report a fall that resulted in injury within the required 5 working days to the State Agency.
Findings
The facility failed to report a fall with injury investigation report to the State Agency within 5 working days as required by regulation. Resident 3 fell on 6/26/2012, reported pain on 6/27/2012, and was found to have a fractured pelvis. The facility had no documented evidence of timely reporting.
Complaint Details
The complaint investigation was triggered by an allegation that the facility failed to report a fall with injury investigation report to the State Agency within 5 working days for Resident 3. The facility census was 47 at the time of the complaint investigation.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to report a fall that resulted in injury investigation report to the State Agency within 5 working days for Resident 3. | SS=D |
Report Facts
Facility census: 47
Resident admission date: Jun 1, 2012
Fall date: Jun 26, 2012
MDS assessment date: Jun 11, 2012
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Hochstetler | Administrator | Named in administrative correspondence |
| George Voigtlander | Physician Reviewer/Medical Director | Conducted informal dispute resolution and reviewed findings |
| Eye Lewis | RNC, Administrator | Signed plan of correction and correspondence |
| Janis D'amico | RN | Participant in informal dispute resolution |
| Timothy McAvoy | MD | Participant in informal dispute resolution |
| Nancy Granlund | Regional Director of Operations | Participant in informal dispute resolution |
| Chris Somer | Director of Nursing | Participant in informal dispute resolution and interview |
| Carolyn Walburg | MD | Participant in informal dispute resolution |
| LPN-D | Licensed Practical Nurse | Interviewed regarding Resident 3 fall |
Inspection Report
Census: 59
Deficiencies: 14
May 7, 2012
Visit Reason
The inspection was conducted as a regulatory survey to assess compliance with state and federal regulations governing skilled nursing facilities, including life safety code compliance.
Findings
The facility was found deficient in multiple areas including failure to provide residents with Medicaid benefit information upon payor source change, failure to honor resident bathing preferences, inadequate housekeeping and maintenance leading to disrepair in resident rooms, incomplete comprehensive assessments especially related to pressure ulcers, failure to implement fall prevention care plans, delayed response to call lights, failure to maintain nutritional status and provide adequate nutritional interventions, failure to ensure drug regimens included indications for use, failure to maintain proper food temperature and sanitary food handling practices, and multiple life safety code violations including improper fire door closures, improperly mounted alcohol-based hand rub dispensers, malfunctioning delayed egress door, and use of unapproved electrical power strips.
Severity Breakdown
SS=F: 5
SS=E: 3
SS=D: 6
Deficiencies (14)
| Description | Severity |
|---|---|
| Facility failed to provide Medicaid benefit information to Resident 16 after payor source changed to Medicaid. | SS=D |
| Facility failed to honor Resident 32's choice for bath schedule. | SS=D |
| Facility failed to maintain cleanable surfaces in good repair in resident rooms 404, 408, 606, and 607. | SS=E |
| Facility failed to provide a comprehensive skilled assessment for Resident 88's pressure ulcer. | SS=D |
| Facility failed to implement care plan interventions to prevent falls for Resident 9. | SS=D |
| Facility failed to ensure call lights were answered timely to resident satisfaction affecting multiple residents. | SS=E |
| Facility failed to plan and implement interventions to prevent unplanned weight loss for Resident 42 and failed to provide nutritional interventions for Resident 40. | SS=D |
| Facility failed to ensure drug regimens for Residents 09, 38, and 43 included indications for each medication prescribed. | SS=D |
| Facility failed to ensure food was served at proper temperature and palatable to residents. | SS=E |
| Facility failed to ensure staff removed gloves and washed hands when contaminated, increasing risk of foodborne illness. | SS=F |
| Facility failed to properly mount alcohol-based hand rub dispensers at least 12 inches from ignition sources. | SS=F |
| Facility failed to maintain delayed egress door in skilled dining room to function properly. | SS=F |
| Facility failed to supply enough hard-wired electrical outlet receptacles in the Day Room and used unapproved relocatable power tap. | SS=D |
| Facility failed to ensure proper closure of fire doors for corridor openings and smoke partitions. | SS=F |
Report Facts
census: 59
weight_loss_percentage: 5.74
weight_loss_percentage: 4.92
temperature: 132
temperature: 116
temperature: 134
temperature: 101.6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Responsible for reviewing Medicaid benefit information with residents/families | |
| Licensed Practical Nurse (LPN-N) | Facility wound treatment nurse who reported lack of documentation and interventions for pressure ulcer | |
| Director of Nursing (DON) | Reported expectations for call light response and fall prevention interventions | |
| Dietary Manager | Reported food temperature monitoring practices and hand washing issues | |
| Dietetic Technician | Hired to screen new admits for nutrition interventions and educate staff on wound care protocol | |
| Maintenance Supervisor | Responsible for fire door education and adjustments, and relocating alcohol-based hand rub dispensers |
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 1
Jul 20, 2011
Visit Reason
The inspection was conducted based on a complaint investigation regarding infection control practices, specifically the facility's failure to prevent the spread of MRSA and other infections between resident roommates.
Findings
The facility failed to implement and maintain an effective Infection Prevention and Control Program to prevent the spread of infections, including MRSA, between residents. This affected multiple residents, including Residents 03, 17, 18, and 102, with issues such as inappropriate roommate placement and shared use of linens contributing to infection spread.
Complaint Details
The complaint investigation found that Resident 03 was moved into a room with Resident 102 who had active MRSA, exposing Resident 03 to potential infection. Additionally, Residents 17 and 18 in the same room developed eye infections suggestive of transmission via shared towels. The facility lacked guidelines to prevent transmission of infections to roommates.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to implement and maintain an Infection Prevention and Control Program to prevent the spread of infection, including MRSA, between resident roommates. | SS=D |
Report Facts
Facility census: 60
Survey sample size: 6
Dates of infection onset: 2011
Inspection Report
Enforcement
Deficiencies: 0
Feb 9, 2011
Visit Reason
The survey was conducted by the Nebraska Department of Health and Human Services to determine if the facility was in compliance with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The facility was found not to be in substantial compliance with participation requirements on February 9, 2011, and a revisit on April 6, 2011 confirmed continued noncompliance. Consequently, payment for new Medicare and Medicaid admissions was denied effective April 30, 2011. A subsequent revisit on May 16, 2011 established that corrections had been made and substantial compliance was achieved, leading to removal of the denial of payment.
Report Facts
CMP amount: 5000
Days until termination: 181
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dan Stauffer | Administrator | Facility administrator addressed in the letters |
| Jennifer King | Branch Manager | Survey, Certification & Enforcement Branch, sender of the initial enforcement letter |
| Jane Weiler | Health Quality Review Specialist | Survey, Certification & Enforcement Branch, sender of the letter confirming substantial compliance |
Inspection Report
Routine
Census: 62
Capacity: 68
Deficiencies: 11
Feb 3, 2011
Visit Reason
The inspection was a routine survey to assess compliance with state and federal regulations governing skilled nursing and retirement facilities, including infection control, dignity and respect of residents, dietary services, and life safety code standards.
Findings
The facility was found deficient in multiple areas including dignity and respect of residents, reasonable accommodation of needs/preferences, safe and comfortable environment, ADL care, nutrition status, infection control, and life safety code compliance. Deficiencies included failure to maintain resident dignity in dining areas, inadequate dietary accommodations, unsafe storage of bleach, improper hand hygiene and food handling practices, and failure to maintain exit discharge lighting. Plans of correction were submitted with specific corrective actions and dates.
Severity Breakdown
D: 3
E: 6
F: 2
G: 1
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to provide dignity and respect by not covering residents properly in the dining room. | E |
| Failure to accommodate individual preferences during meal service. | D |
| Failure to provide a safe, clean, comfortable and homelike environment by not securing bleach in laundry room. | D |
| Failure to maintain comfortable and safe temperature levels in dining room. | E |
| Failure to assess residents for amount of assistance needed with dining and provide consistent dining assistance. | D |
| Failure to plan and monitor nutritional interventions to promote healing of pressure sores. | D |
| Failure to maintain nutrition status and evaluate residents for weight loss and dietary needs. | G |
| Failure to ensure therapeutic diets are provided as prescribed by physicians. | E |
| Failure to follow dietary menus and serve specified protein portions and food consistency. | E |
| Failure to maintain infection control practices including hand hygiene and glove use. | E |
| Failure to maintain life safety code standards including exit discharge lighting and fire drills. | F |
Report Facts
Facility census: 62
Total capacity: 68
Survey sample size: 15
Deficiency counts: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dan Stauffer | Executive Director | Signed Plan of Correction and referenced in findings related to dignity and respect, environmental audits, and dietary services |
| Mary D. Litchford | Advanced Practitioner | Referenced in nutritional interventions and wound healing guidance |
| Registered Dietitian | Registered Dietitian (RD) | Referenced throughout report for dietary assessments, menu reviews, and nutritional interventions |
| Interim Director of Nursing | IDON | Interviewed regarding resident assistance and care |
| Director of Nurses | DON | Interviewed regarding resident care expectations and dietary audits |
| Dietary Manager | DM | Referenced for dietary audits, menu compliance, and staff education |
Document
Capacity: 68
Deficiencies: 0
Visit Reason
The documents include a nursing home licensure renewal application, occupancy permits issued by the Nebraska State Fire Marshal, ownership and corporate structure information, and a facility layout showing 68 total beds.
Findings
No inspection findings or deficiencies are reported. The documents verify licensure renewal, occupancy permits, and ownership details for Centennial Park Retirement Village.
Report Facts
Total licensed beds: 68
Document
Capacity: 68
Deficiencies: 0
Visit Reason
This document serves as a license renewal application for Centennial Park Retirement Village nursing home and includes ownership and corporate structure information, as well as a fire marshal occupancy permit.
Findings
The documents confirm the facility's licensed capacity of 68 beds, ownership by Five Star Quality Care-NE, LLC, and include a fire marshal occupancy permit issued on 11/3/2015. No inspection findings or deficiencies are reported.
Report Facts
Licensed capacity: 68
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tina Muller | Administrator | Named in license renewal application |
| Christine Johansen | Director of Nursing | Named in license renewal application |
| Bruce J. Mackey Jr. | President & Chief Executive Officer | Named as officer of Five Star Quality Care-NE, LLC |
| R. Scott Herzig | Senior Vice President & Chief Operating Officer | Named as officer of Five Star Quality Care-NE, LLC |
| Richard A. Doyle | Treasurer & Chief Financial Officer | Named as officer of Five Star Quality Care-NE, LLC |
| Katherine E. Potter | Vice President, General Counsel & Assistant Secretary | Named as officer of Five Star Quality Care-NE, LLC |
| Jennifer B. Clark | Corporate Secretary | Named as officer of Five Star Quality Care-NE, LLC |
| Barry M. Portnoy | Director | Named as director of Five Star Quality Care-NE, LLC |
| Gerard M. Martin | Director | Named as director of Five Star Quality Care-NE, LLC |
Notice
Capacity: 68
Deficiencies: 0
Visit Reason
This document serves as a licensure renewal application and certification for Centennial Park Retirement Village, verifying the facility's license status and renewal through the indicated date.
Findings
The documents confirm the facility's licensure renewal status, ownership structure, and occupancy permit with a total licensed capacity of 68 beds. No inspection findings or deficiencies are reported.
Report Facts
Total licensed beds: 68
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Cynthia Wheeler | Administrator | Named as Administrator on the Nursing Home Licensure Renewal Application. |
| Christine Johansen | Director of Nursing | Named as Director of Nursing on the Nursing Home Licensure Renewal Application. |
Notice
Capacity: 68
Deficiencies: 0
Visit Reason
This document serves as a license renewal verification for Centennial Park Retirement Village and includes occupancy permits and ownership information.
Findings
The documents confirm the facility's licensure through the renewal date, ownership structure, and maximum occupancy as per fire marshal permits. No inspection findings or deficiencies are reported.
Report Facts
Total licensed beds: 68
Maximum occupancy: 57
Maximum occupancy: 67
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Beth Block | Administrator | Named on the renewal application (page 2). |
| Christine Johansen | Director of Nursing | Named on the renewal application (page 2). |
| Katherine E. Potter | President and Chief Executive Officer | Named as officer of ownership entity Five Star Quality Care-NE, LLC (page 5). |
| Richard A. Doyle | Executive Vice President, Chief Financial Officer and Treasurer | Named as officer of ownership entity Five Star Quality Care-NE, LLC (page 5). |
| Lisa J. Cooney | Senior Vice President, General Counsel and Assistant Secretary | Named as officer of ownership entity Five Star Quality Care-NE, LLC (page 5). |
| Jennifer B. Clark | Secretary | Named as officer of ownership entity Five Star Quality Care-NE, LLC (page 5). |
| Gerard M. Martin | Director | Named as director of ownership entity Five Star Quality Care-NE, LLC (page 5). |
| Adam D. Portnoy | Director | Named as director of ownership entity Five Star Quality Care-NE, LLC (page 5). |
| Dana Reece | Deputy State Fire Marshal | Inspected and approved the Nebraska State Fire Marshal Occupancy Permit (page 10). |
Notice
Capacity: 94
Deficiencies: 0
Visit Reason
The documents serve to verify the renewal of the SNF/NF dual certification license and to provide occupancy permit information for The Maples at Centennial nursing home.
Findings
The documents confirm that The Maples at Centennial meets statutory requirements for licensure renewal and holds an occupancy permit for 94 beds, with no deficiencies or inspection findings noted.
Report Facts
Total licensed beds: 94
Renewal license expiration date: Mar 31, 2026
Occupancy permit issue date: Nov 26, 2024
Document
Capacity: 68
Deficiencies: 0
Visit Reason
The documents include issuance and renewal of the Skilled Nursing Facility license for Centennial Park Retirement Village, ownership and corporate structure disclosures, fire marshal occupancy permit, and a bill of sale and assignment agreement related to the facility's ownership transfer.
Findings
No inspection findings or deficiencies are reported. The documents primarily certify licensure, ownership, and compliance with regulatory requirements such as fire safety occupancy limits.
Report Facts
Total licensed beds: 68
Occupancy limit: 67
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Beth Block | Administrator | Named as facility administrator in licensure application. |
| Christine Johansen | Director of Nursing | Named as director of nursing in licensure application. |
| Gary J. Anthone, MD | Chief Medical Officer, Director, Division of Public Health | Signed licensing and renewal documents for the Nebraska Department of Health and Human Services. |
| Richard W. Siedel, Jr. | Chief Financial Officer and Treasurer | Signed bill of sale and corporate documents as authorized representative of SNH Neb Tenant LLC. |
| Jennifer F. Francis | President & COO | Named as authorized representative of ownership entity SNH Neb Tenant LLC. |
| Dana Reece | Deputy State Fire Marshal | Inspected facility for fire marshal occupancy permit. |
Notice
Capacity: 57
Deficiencies: 0
APP2016
Visit Reason
This document serves as a licensure renewal application for the assisted-living facility Centennial Park Retirement Village, LTD, verifying that the facility is licensed through the date indicated on the renewal card.
Findings
The document confirms the facility's licensure status and provides ownership, corporate structure, and fire department certificate of occupancy information. No inspection findings or deficiencies are reported.
Report Facts
Total licensed beds: 57
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tina Muller | Administrator | Named as administrator on the licensure renewal application (page 2). |
| Richard A. Doyle | Treasurer & Chief Financial Officer | Listed as officer in ownership control section (page 4). |
| Bruce J. Mackey Jr. | President & Chief Executive Officer | Listed as officer in ownership control section (page 4). |
| R. Scott Herzig | Senior Vice President & Chief Operating Officer | Listed as officer in ownership control section (page 4). |
| Katherine E. Potter | Vice President, General Counsel & Assistant Secretary | Listed as officer in ownership control section (page 4). |
| Jennifer B. Clark | Corporate Secretary | Listed as officer in ownership control section (page 4). |
| Barry M. Portnoy | Director | Listed as director in ownership control section (page 4). |
| Gerard M. Martin | Director | Listed as director in ownership control section (page 4). |
Notice
Capacity: 68
Deficiencies: 0
APP2020
Visit Reason
This document serves as a renewal application for the nursing home license of Centennial Park Retirement Village and includes related licensing and occupancy permit information.
Findings
The documents certify that Centennial Park Retirement Village meets statutory requirements for SNF/NF dual certification and holds a valid occupancy permit for 68 beds. Ownership and management structure details are provided.
Report Facts
Total licensed beds: 68
Renewal license expiration date: Mar 31, 2021
Occupancy permit issue date: Aug 19, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer F. Francis | President & COO | Listed as authorized representative and owner/officer in ownership information. |
| Richard W. Siedel Jr. | Treasurer & CFO | Listed as authorized representative and owner/officer in ownership information. |
| Jennifer B. Clark | Secretary, Director | Listed as owner/officer in ownership information. |
| Adam D. Portnoy | Director | Listed as owner/officer in ownership information. |
Notice
Capacity: 57
Deficiencies: 0
APP2017
Visit Reason
This document serves as a licensure renewal application and renewal notice for the assisted-living facility Centennial Park Retirement Village, LTD, verifying the facility's license through the indicated renewal date.
Findings
The document confirms that the facility meets statutory requirements for licensure as an assisted-living facility and includes ownership, capacity, and certification details.
Report Facts
Total licensed beds: 57
Maximum occupancy: 57
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Tina Muller | Administrator | Named as facility administrator in the renewal application |
| Bruce J. Mackey Jr. | President & Chief Executive Officer | Listed as officer of Five Star Quality Care-NE, LLC in ownership structure |
| R. Scott Herzig | Senior Vice President & Chief Operating Officer | Listed as officer of Five Star Quality Care-NE, LLC in ownership structure |
| Richard A. Doyle | Treasurer & Chief Financial Officer | Listed as officer of Five Star Quality Care-NE, LLC in ownership structure |
| Katherine E. Potter | Vice President, General Counsel & Assistant Secretary | Listed as officer of Five Star Quality Care-NE, LLC in ownership structure |
| Jennifer B. Clark | Corporate Secretary | Listed as officer of Five Star Quality Care-NE, LLC in ownership structure |
| Barry M. Portnoy | Director | Listed as director of Five Star Quality Care-NE, LLC in ownership structure |
| Gerard M. Martin | Director | Listed as director of Five Star Quality Care-NE, LLC in ownership structure |
Document
Capacity: 68
Deficiencies: 0
Visit Reason
The documents pertain to the renewal of the nursing home license for Azria Health Centennial Park, including verification of licensure, ownership information, and occupancy permit details.
Findings
No inspection findings or deficiencies are reported. The documents confirm licensure renewal, ownership, and occupancy capacity of 68 beds.
Report Facts
Total licensed beds: 68
Renewal license fees: 1550
Renewal license fees: 1750
Renewal license fees: 1950
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Julie Skala | Administrator | Named on the Nursing Home Licensure Renewal Application. |
| Christine Johansen | Director of Nursing | Named on the Nursing Home Licensure Renewal Application. |
| Steven Hornung | Authorized Representative | Signed the Nursing Home Licensure Renewal Application. |
| Noah Kaminer | Authorized Representative | Signed the Nursing Home Licensure Renewal Application. |
| Michael Hoeft | Deputy State Fire Marshal | Inspected the facility and approved the occupancy permit. |
Notice
Deficiencies: 0
DAN020911
Visit Reason
The document serves as a Notice of Disciplinary Action placing the facility on probation for 90 days starting March 10, 2011, due to failure to evaluate residents and implement nutritional interventions to prevent significant weight loss, with a subsequent modification extending probation to 180 days and prohibiting new admissions until compliance is met.
Findings
The facility failed to evaluate residents and implement nutritional interventions to prevent significant weight loss, failed to ensure proper ventilation and sanitation, and failed to ensure nursing personnel performed required hand hygiene and glove changing during care.
Report Facts
Probation period: 90
Probation period: 180
Probation start date: Mar 10, 2011
Probation end date: Sep 6, 2011
Report due date: Mar 20, 2011
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Joann Schaefer | Chief Medical Officer | Signed the Notice of Disciplinary Action and Modification of Disciplinary Action |
| Helen L. Meeks | Administrator, Licensure Unit | Signed the Notice of Disciplinary Action and Modification of Disciplinary Action |
| Eve Lewis | RNC, Administrator, Administrator, Office of Long Term Care Facilities | Administrator who sent letter terminating probation and restoring license status |
Notice
Capacity: 57
Deficiencies: 0
APP2019
Visit Reason
This document serves as a licensure renewal application and renewal notice for Centennial Park Retirement Village, an assisted-living facility, verifying that the facility is licensed through the indicated expiration date.
Findings
The document confirms the facility's licensure status and includes ownership information, accreditation status, and certification of compliance with state regulations. It also includes a certificate of occupancy indicating a maximum occupancy of 57 persons.
Report Facts
Total licensed beds: 57
Maximum occupancy: 57
Notice
Capacity: 68
Deficiencies: 0
Visit Reason
The documents serve to verify the renewal of the SNF/NF dual certification license for Azria Health Centennial Park and include the renewal application, ownership information, and occupancy permit.
Findings
No inspection findings or deficiencies are reported; the documents confirm licensure renewal, ownership details, and occupancy permit issuance.
Report Facts
Total licensed beds: 68
Renewal license fees: 1550
Renewal license fees: 1750
Renewal license fees: 1950
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicholas Mann | Facility Administrator | Named in ownership and control list on renewal application. |
| Johanna Hehns | Director of Nursing | Named on renewal application. |
| Aaron N Kaminer | Authorized Representative | Signed renewal application. |
| Steven Hornung | Authorized Representative | Signed renewal application and listed as manager of licensed operator. |
| Michael Hoeft | Deputy State Fire Marshal | Inspected facility and approved occupancy permit. |
Notice
Capacity: 57
Deficiencies: 0
APP2021
Visit Reason
This document serves as a renewal application and verification of licensure for the assisted-living facility Azria Health Centennial Park.
Findings
The documents confirm that Azria Health Centennial Park meets statutory requirements as an assisted-living facility and is licensed through the renewal date indicated. No inspection findings or deficiencies are reported.
Report Facts
Total licensed beds: 57
Bed count: 42
Renewal license expiration date: Apr 30, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Winsome Backer | Administrator | Named as facility administrator on renewal application |
| Steve Hornung | Owner | Listed as owner in ownership control list |
| Noah Kaminer | Owner | Listed as owner in ownership control list and signed renewal application |
Notice
Capacity: 68
Deficiencies: 0
Visit Reason
The documents pertain to the renewal of the nursing home license for Azria Health Centennial Park and verification of ownership and occupancy permit compliance.
Findings
No inspection findings or deficiencies are reported. The documents certify licensure renewal, ownership control, and occupancy permit issuance with fire safety floor plans.
Report Facts
Total licensed beds: 68
Renewal license expiration date: Expires 3/31/2024 as shown on renewal card
Occupancy permit issue date: Issued 4/12/2022 as shown on occupancy permit
Renewal license fees: 1750
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nolan Gurnsey | Administrator | Named on renewal application and ownership verification letter |
| Johanna Heinis | Director of Nursing | Named on renewal application |
| Steve Hornung | Named on ownership verification letter | |
| Aaron Kaminer | Named on ownership verification letter | |
| Michael Hoeft | Deputy State Fire Marshal | Inspected and approved occupancy permit |
Notice
Capacity: 68
Deficiencies: 0
APP2022
Visit Reason
The document serves as a renewal application and verification of licensure for the assisted-living facility Azria Health Centennial Park, including occupancy permit details.
Findings
The documents confirm the facility meets statutory requirements for licensure renewal and provide occupancy limits as per the state fire marshal's permit.
Report Facts
Total licensed beds: 68
Beds to be relicensed: 57
Assisted Living Bed Count: 42
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Nicholas Mann | Administrator | Named as facility administrator on renewal application and control list |
| Aaron Kaminer | Authorized Representative | Signed renewal application and listed as manager of licensed operator |
| Steve Hornung | Authorized Representative | Signed renewal application and listed as manager of licensed operator |
Notice
Deficiencies: 0
DAN073113
Visit Reason
The document serves as a Notice of Disciplinary Action against Centennial Park Retirement Village for failure to develop and maintain systems to prevent significant weight loss in residents, placing the facility on probation for 90 days starting August 30, 2013.
Findings
The facility was found to have violations related to unplanned weight loss and quality assurance/performance improvement, issues cited in the last three annual surveys. The Department requires a Plan of Correction and ongoing reporting during the probation period.
Report Facts
Probation period length: 90
Report due date: 2013
Monthly report due date: 2013
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | RNC, Administrator | Recipient of required reports and contact for response. |
| Joseph M. Acierno | M.D., J.D., 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 of Disciplinary Action. |
Notice
Capacity: 68
Deficiencies: 0
Visit Reason
This document serves as a renewal application and verification of licensure for The Maples at Centennial nursing home facility, confirming the renewal of the SNF/NF dual certification and related licensing information.
Findings
The documents confirm the facility's licensure renewal, ownership details, bed capacity, and occupancy permit. No inspection findings or deficiencies are reported.
Report Facts
Total licensed beds: 68
Renewal license expiration date: 2024
Occupancy permit date issued: 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Johanna Heinis | Administrator | Named in the Nursing Home Licensure Renewal Application. |
| Jen Belgum | Director of Nursing | Named in the Nursing Home Licensure Renewal Application. |
| Ari Silberstein | Authorized Representative | Signed the Nursing Home Licensure Renewal Application. |
| Michael Hoeft | Deputy State Fire Marshal | Inspected the facility and approved the occupancy permit. |
Notice
Capacity: 57
Deficiencies: 0
APP2023
Visit Reason
This document serves as a renewal application and verification of licensure for the assisted-living facility Azria Health Centennial Park, including ownership verification and occupancy certification.
Findings
The documents confirm the facility meets statutory requirements for licensure renewal, with no inspection findings or deficiencies reported.
Report Facts
Total licensed beds: 57
License expiration date: Apr 30, 2024
Maximum occupancy: 57
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Aaron Kaminer | Named as authorized representative signing the renewal application on page 2 | |
| Steve Hornung | Named as authorized representative signing the renewal application on page 2 | |
| Nolan Gurnsey | Named in ownership verification letter on page 3 |
Notice
Deficiencies: 0
DAN110424
Visit Reason
This Notice of Disciplinary Action was issued to The Maples At Centennial Nursing Facility due to violations related to failure to identify causative factors and develop and implement new interventions for resident falls, as documented in the CMS-2567 Report dated October 28, 2024.
Findings
The facility is prohibited from admitting residents until compliance is demonstrated. The license is placed on probation for 180 days starting November 19, 2024, requiring submission of a Plan of Correction addressing violations related to accidents and resident falls, including assessment methods, interventions, documentation, and evaluation processes.
Report Facts
Probation period days: 180
Date of CMS-2567 Report: Oct 28, 2024
Deadline for first report: Nov 29, 2024
Notice date: Nov 4, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Timothy Tesmer | Chief Medical Officer | Signed the Notice of Disciplinary Action |
| Dan Taylor | Administrator | Named in the Notice as Health Facilities Licensure Unit Administrator |
| Kolby Verger | Administrative Specialist | Signed Certificate of Service for the Notice |
Notice
Capacity: 57
Deficiencies: 0
APP2025
Visit Reason
The document serves as a renewal license application and verification for the assisted-living facility The Maples at Centennial, confirming its licensure status and ownership information.
Findings
The documents confirm the facility's licensure renewal, ownership structure, and maximum licensed capacity of 57 beds. No inspection findings or deficiencies are reported.
Report Facts
Total licensed beds: 57
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Johanna Heinis | Administrator | Listed as facility administrator on the renewal application. |
| Devora Kirschner | Authorized Representative | Signed the renewal application on behalf of the facility. |
| Ari Silberstein | Authorized Representative | Signed the renewal application on behalf of the facility. |
| David Weisz | Authorized representatives to sign license renewal applications. |
Document
Capacity: 57
Deficiencies: 0
CHOW2020
Visit Reason
The documents pertain to the licensing, ownership, and regulatory compliance of Centennial Park Retirement Village, including issuance of an assisted living facility license, ownership disclosures, certificate of occupancy, and property management transfer.
Findings
The documents confirm the facility's licensure as an assisted living facility, ownership by SNH Neb Tenant LLC, a licensed capacity of 57 beds, and compliance with fire safety occupancy limits. A bill of sale and assignment agreement for property management transfer is also included.
Report Facts
Licensed beds: 57
Maximum occupancy: 57
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Beth Block | Administrator | Named as facility administrator in licensure application. |
| Gary J. Anthone | Chief Medical Officer, Director, Division of Public Health | Signed licensing documents for the Nebraska Department of Health and Human Services. |
| Jennifer F. Francis | President & COO | Authorized representative of SNH Neb Tenant LLC and Senior Housing Properties Trust ownership. |
| Richard W. Siedel, Jr. | CFO & Treasurer | Authorized representative of SNH Neb Tenant LLC and signatory on bill of sale and assignment agreement. |
| Jeffrey C. Leer | Executive Vice President, Chief Financial Officer and Treasurer | Signatory on bill of sale and assignment agreement for Westgate Assisted Living property transfer. |
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