Deficiencies per Year
8
6
4
2
0
Unclassified
Census Over Time
Inspection Report
Renewal
Capacity: 64
Deficiencies: 0
Mar 21, 2023
Visit Reason
The document is a renewal application and license verification for Valley Lakes Assisted Living facility, confirming licensure through the renewal date and requesting renewal of the facility license.
Findings
The document certifies that Valley Lakes Assisted Living meets statutory requirements as an assisted-living facility and includes ownership and occupancy information, with no deficiencies or inspection findings noted.
Report Facts
Total licensed beds: 64
Renewal application date: Mar 21, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kristina Pryor | Administrator | Named on renewal application as facility administrator |
| Gregory Fonda | Authorized Representative | Signed renewal application on 2023-03-21 |
| Ty Hermes | Deputy State Fire Marshal | Inspected facility and approved occupancy permit |
Inspection Report
Renewal
Capacity: 64
Deficiencies: 0
Mar 10, 2022
Visit Reason
This document serves as a renewal application and license verification for Valley Lakes Assisted Living facility to confirm licensure through the renewal date.
Findings
The documents confirm that Valley Lakes Assisted Living meets statutory requirements for licensure as an assisted-living facility with a maximum capacity of 64 beds. The renewal application and occupancy permit are included.
Report Facts
Total licensed beds: 64
Inspection Report
Renewal
Capacity: 64
Deficiencies: 0
Mar 30, 2021
Visit Reason
The document is a renewal application and certification for the assisted-living facility Valley Lakes Assisted Living, verifying the facility's license renewal and compliance with state regulations.
Findings
The document certifies that Valley Lakes Assisted Living meets statutory requirements as an assisted-living facility and is licensed through the renewal date. It includes ownership information and confirms the facility's total licensed bed capacity.
Report Facts
Total licensed beds: 64
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kristina Pryor | Administrator | Named as the facility administrator in the renewal application |
| Christopher R. Held | Authorized Representative | Signed the renewal application on 2021-03-30 |
Inspection Report
Complaint Investigation
Deficiencies: 0
Jul 25, 2019
Visit Reason
An unannounced visit was conducted to investigate a complaint alleging the facility failed to ensure prompt emergency care for potentially life threatening situations.
Findings
The facility was found to ensure prompt emergency care for potentially life threatening situations based on interviews with staff and residents and review of resident records, with residents reporting satisfaction and records showing updates to responsible parties and physicians.
Complaint Details
The complaint alleged failure to ensure prompt emergency care for potentially life threatening situations. The complaint was not substantiated as the facility was found 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: 1
Jan 29, 2018
Visit Reason
An unannounced visit was conducted to investigate a complaint at Orchard Gardens on January 29-30, 2018, regarding allegations of mold presence, medication administration errors, and failure to provide care according to practitioner's orders.
Findings
The facility was found to have had mold in a heating/air conditioning closet, substantiating that allegation, but corrections were implemented and compliance was achieved. Medication administration and provision of care were found to be in compliance with medical practitioner orders and regulatory requirements.
Complaint Details
The complaint investigation substantiated the allegation of mold presence but found the facility compliant after corrective actions. Allegations related to medication administration and care provision were not substantiated.
Deficiencies (1)
| Description |
|---|
| Failure to ensure a mold free environment in a heating/air conditioning closet. |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator | Signed the report as Training Coordinator, Office of LTC Facilities - Licensure Unit - Division of Public Health |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 7
Feb 24, 2016
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Orchard Gardens on February 24-25, 2016, by representatives of the Department of Health and Human Services Division of Public Health.
Findings
The facility was found to be in compliance with many regulatory requirements including protection from misappropriation, abuse prevention, staffing, and service provision. However, deficiencies were found related to medication administration errors, incomplete staff ongoing training, failure to assess safety of self-medication for some residents, missing allergy documentation on medication records, inadequate hand hygiene and hair restraint use in food service, environmental safety hazards including unsecured chemicals and a hot fireplace, and failure to clean equipment during medication pass.
Complaint Details
The complaint investigation included allegations of failure to protect residents from misappropriation, failure to report and investigate misappropriation, failure to provide services as agreed, inadequate staffing, medication errors, failure to protect from abuse, and failure to meet retention criteria. The facility was found compliant on misappropriation, abuse, staffing, service provision, and retention criteria but noncompliant on medication administration and other safety issues.
Deficiencies (7)
| Description |
|---|
| Direct Care Staff failed to complete required 12 hours of ongoing training for three employees. |
| Facility failed to assess safety of self-medication for two residents (Residents 9 and 11). |
| Medication administration errors occurred: Resident 3 received double dose of Oxycodone; Resident 6 received wrong medication (Seroquel instead of Zoloft) for 5 days. |
| Resident allergies were not documented on Medication Administration Records for three residents (Residents 1, 10, and 11). |
| Facility staff failed to use proper handwashing and hair restraints in food preparation and service areas, risking foodborne illness. |
| Facility staff failed to perform proper hand hygiene and clean equipment during medication pass, risking cross contamination affecting six residents. |
| Facility failed to maintain environmental safety: hot fireplace in lobby posed burn risk to a confused resident; chemicals were unsecured in housekeeping carts and custodial closet accessible to residents. |
Report Facts
Medication pass opportunities observed: 27
Medication errors for Resident 6: 5
Direct Care Staff training hours: 9
Facility census: 56
Fireplace temperature: 169.2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | Program Manager - Office of LTC Facilities - Licensure Unit | Signed the report letter. |
| Brenda Harbison | Registered Nurse | Surveyor involved in inspection. |
| Kelly Darling | Registered Nurse | Surveyor involved in inspection. |
| Lori Frodsham | Registered Nurse | Surveyor involved in inspection. |
| Carol Neneman | Social Worker | Surveyor involved in inspection. |
| Director of Senior Housing | Interviewed regarding training, medication administration, and safety policies. | |
| Medication Aide A | Observed failing hand hygiene during medication pass and incomplete training hours. | |
| Medication Aide B | Had incomplete training hours. | |
| Medication Aide C | Had incomplete training hours. | |
| Dietary Manager | Interviewed about food safety practices. | |
| Maintenance Director | Interviewed about custodial closet security. |
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 5
Jun 13, 2011
Visit Reason
An onsite inspection was conducted to determine compliance with regulatory requirements following a complaint or allegation.
Findings
The facility was found to have multiple violations including failure to provide evidence of nurse aide registry checks, incomplete recipient safety determinations for medication administration, failure to ensure controlled substances documentation, food safety violations, and failure to maintain proper bathing and handwashing water temperatures.
Complaint Details
The inspection was complaint-related as indicated by the visit reason and findings addressing specific allegations of noncompliance.
Deficiencies (5)
| Description |
|---|
| Failed to provide evidence of nurse aide registry checks for 3 of 5 sampled direct care staff. |
| Failed to complete recipient safety determination for 4 of 4 sampled residents receiving medications from medication aides. |
| Failed to ensure controlled substances were documented and counts signed by both staff members for sampled residents. |
| Failed to use sanitizer properly, failed to change gloves after handling paper menus, failed to wash hands after handling dirty dishes or raw foods, failed to use effective hair restraints, and failed to have testing strips available for sanitizer. |
| Failed to maintain hot water temperatures in the whirlpool bath above 115 degrees Fahrenheit. |
Report Facts
Census: 49
Sampled direct care staff: 5
Residents reviewed for medication safety: 4
Controlled substances counts: 4
Residents affected by food safety violations: 49
Hot water temperature: 118
Hot water temperature: 120
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kay Reeves | Nutrition/dietitian | Surveyor conducting the inspection. |
| Nikki Ingram | Administrator | Administrator who confirmed no documentation of nurse aide registry checks and signed facility response letter. |
| Eve Lewis | RN-C, Administrator | Office of Long Term Care Facilities Administrator who signed letters related to the inspection. |
| Director of Resident Services | Confirmed recipient safety determinations had not been completed and acknowledged controlled substance count issues. | |
| Dietary Staff Member F | Observed using Clorox wipes to clean and sanitize food thermometer. | |
| Dietary Staff Member G | Observed handling paper menus and bread with same gloves and cracking raw egg without washing hands. | |
| Dietary Staff Member H | Observed spraying off and positioning dirty pans on dishwasher without washing hands. | |
| Direct Care Staff Member H | Observed returning soiled glass and picking up plate of food without washing hands. | |
| Medication Aide D | Interviewed regarding controlled substance counts and medication administration. | |
| Medication Aide E | Interviewed regarding controlled substance counts and medication administration. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Mar 24, 2011
Visit Reason
The inspection was conducted to investigate allegations that the facility failed to provide necessary services to prevent harm, failed to administer medications according to practitioner's orders, and failed to provide care as per the Resident Service Agreement.
Findings
The facility was found to have not committed any violations. Services were provided to prevent harm, medications were administered according to physician's orders, and care was provided as per Resident Service Agreements.
Complaint Details
The complaint allegations included failure to provide necessary services to prevent harm, failure to administer medications according to practitioner's orders, and failure to provide care as per the Resident Service Agreement. The facility was found not to be in violation of these allegations.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | Administrator | Signed the correspondence from the Office of Long Term Care Facilities |
| Kay Reeves | Nutrition/dietitian Surveyor | Conducted the onsite inspection |
Notice
Capacity: 64
Deficiencies: 0
APP2016
Visit Reason
The document serves as a licensure renewal application and verification for the assisted-living facility Orchard Gardens, including renewal fee information and occupancy permit details.
Findings
The documents confirm that Orchard Gardens meets statutory requirements for licensure as an assisted-living facility with a licensed capacity of 64 beds. The occupancy permit was issued by the State Fire Marshal with no noted deficiencies.
Report Facts
Total licensed beds: 64
Renewal fee: 1650
Occupancy permit beds: 64
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kristina Pryor | Administrator | Named as the facility administrator on the licensure renewal application on page 2. |
| Sheila Miller | Chief Executive Officer | Named as CEO of Douglas County Housing Authority, the ownership entity, on page 3. |
Notice
Capacity: 64
Deficiencies: 0
APP2017
Visit Reason
This document serves as verification that Orchard Gardens Assisted-Living Facility is licensed through the indicated renewal date and includes the renewal application for continued licensure.
Findings
The document confirms that Orchard Gardens meets statutory requirements as an assisted-living facility and provides details on ownership, capacity, and renewal fees. No inspection findings or deficiencies are reported.
Report Facts
Total licensed beds: 64
Renewal fees: 950
Renewal fees: 1450
Renewal fees: 1660
Renewal fees: 1950
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kristina Pryor | Administrator | Named as facility administrator in the renewal application |
| Sheila Miller | Chief Executive Officer | Named as CEO of Douglas County Housing Authority, the ownership entity |
Notice
Capacity: 64
Deficiencies: 0
APP2018
Visit Reason
This document serves as a licensure renewal verification for Orchard Gardens Assisted-Living Facility, confirming the facility is licensed through the expiration date indicated on the renewal card.
Findings
The document confirms that Orchard Gardens meets statutory requirements as an assisted-living facility and is licensed through the renewal date. It includes ownership, administrator information, and occupancy permit details.
Report Facts
Total licensed beds: 64
Renewal expiration date: Apr 30, 2019
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kristina Pryor | Administrator | Named as facility administrator on renewal application. |
| Sheila Miller | Chief Executive Officer | Named as CEO of Douglas County Housing Authority, the facility owner. |
Notice
Capacity: 64
Deficiencies: 0
APP2019
Visit Reason
This document serves as a licensure renewal application and renewal notice for the assisted-living facility Orchard Gardens, verifying that the facility is licensed through the expiration date indicated on the renewal card.
Findings
The document confirms that Orchard Gardens meets statutory requirements as an assisted-living facility and provides details about the facility's ownership, capacity, and licensing status.
Report Facts
Total licensed beds: 64
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kristina Pryor | Administrator | Signed the licensure renewal application |
| Sheila Miller | Chief Executive Officer | Authorized representative signing the licensure renewal application and listed as CEO in ownership information |
| Bo Botelho | Interim CEO, Interim Director of Public Health | Signed the license renewal notice from the Department of Health and Human Services |
Notice
Capacity: 64
Deficiencies: 0
APP2020
Visit Reason
This document serves to verify that Valley Lakes Assisted Living is licensed through the indicated renewal date and includes renewal application and occupancy permits.
Findings
The facility is licensed as an assisted-living facility with a total licensed capacity of 64 beds. Occupancy permits issued by the Nebraska State Fire Marshal confirm the maximum occupancy of 64 beds.
Report Facts
Total licensed beds: 64
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kristina Pryor | Administrator | Named in the renewal application form |
| Chris Held | Authorized representative who signed the renewal application | |
| Jason McClun | Deputy State Fire Marshal | Inspected and approved occupancy permits |
Notice
Capacity: 64
Deficiencies: 0
APP2024
Visit Reason
The document serves to verify that Valley Lakes Assisted Living is licensed through the indicated renewal date and includes a renewal application and occupancy permit.
Findings
The documents confirm the facility's licensure renewal status and occupancy permit with a maximum capacity of 64 beds. No inspection findings or deficiencies are reported.
Report Facts
Total licensed beds: 64
Renewal license expiration date: 2025
Notice
Capacity: 64
Deficiencies: 0
APP2025
Visit Reason
This document serves as a renewal license application and verification for Valley Lakes Assisted Living, confirming the facility's licensure and occupancy permit status.
Findings
The documents confirm that Valley Lakes Assisted Living meets statutory requirements for licensure and has an approved occupancy permit with a maximum capacity of 64 beds.
Report Facts
Total licensed beds: 64
Occupancy permit date issued: Feb 4, 2025
Notice
Capacity: 64
Deficiencies: 0
CHOW2019
Visit Reason
This document serves as a license renewal notification and verification that Valley Lakes Assisted Living is licensed as an assisted living facility following a change of ownership and DBA name change effective August 30, 2019.
Findings
The document confirms the issuance of a renewed assisted living facility license to Valley Lakes Assisted Living, replacing the previous license due to ownership and name changes. It includes a licensure card with an expiration date of April 30, 2020.
Report Facts
Total licensed capacity: 64
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kristina Pryor | Administrator | Named as the facility administrator on the licensure application |
| Gary J. Anthone | Chief Medical Officer, Director, Division of Public Health | Signed the license renewal and name change documents |
| Becky Wisell | Administrator, Licensure Unit | Mentioned in the letter issuing the license renewal |
| Connie Vogt | RN, BSN, Program Manager | Contact person for questions about the license |
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