Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Crest View Care Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of falls experienced multiple incidents where root causes were not consistently identified and effective interventions were not implemented or updated in the care plan. Despite repeated falls and injuries, the facility failed to ensure that new or revised fall prevention strategies were put in place, and some interventions were either duplicative or not suitable for the resident's needs.
Expired foods were found in dry storage, including Worcestershire sauce, evaporated milk, and sweetened condensed milk past their dates. In the kitchen, a dietary aide ran dishes through a low-temp dishwasher at temperatures below the facility's required 120 degrees F, and the first two trays were not rewashed. The same aide was also observed with a ponytail hanging unrestrained while working in the food prep area, despite policy and Food Code hair restraint requirements.
The facility failed to ensure a qualified infection preventionist was designated for the infection prevention and control program. Record review showed the Administrator was serving in that role, and the Administrator confirmed this despite not meeting the required qualifications. The Administrator also stated that the Corporate Nurse Consultant was assisting remotely from another state, which did not meet regulatory requirements.
The facility failed to ensure 1 of 5 sampled nurse aides completed the required 12 hours of annual ongoing training. Record review showed an NA had only 6.7 documented training hours during the review period, and the ADM confirmed no additional hours were documented and that the NA should have had 12 hours.
Failure to Protect Residents from Resident-to-Resident Abuse: A resident with dementia, severe cognitive impairment, wandering, agitation, and repeated aggressive behaviors assaulted and threatened multiple other residents. The record showed physical and verbal abuse toward several residents, including striking one resident with a mirror, threatening another with death, standing over a resident who was being hit, threatening violence at supper, and poking a resident with a butter knife. The care record also showed limited documented interventions before and after several of the incidents.
Unnecessary PRN psychotropic use and failure to reassess continued need: A resident with dementia and behavioral disturbances received a PRN antipsychotic without documented non-pharm interventions first, and multiple residents had PRN antipsychotic and anxiolytic orders continued beyond the 14-day limit without provider re-evaluation or documented rationale. Pharmacy reviews repeatedly flagged the issue, but the record showed no evidence the MD addressed the recommendations.
Failure to Investigate Alleged Resident Abuse and Threats: The facility did not initiate or document thorough investigations for multiple resident-to-resident altercations and threats involving a resident with dementia and behavioral disturbances. Incidents included striking another resident with a mirror causing skin tears, threats toward another resident, and additional aggressive statements toward other residents, but the records showed limited staff interviews and no evidence of resident interviews, inability-to-interview documentation, or record review as part of the investigations.
Failure to Document MD Review of Monthly Pharmacy Recs A resident with dementia and multiple PRN psychotropic orders, plus two other residents with dementia-related behaviors, had monthly pharmacist drug regimen review notes that identified irregularities such as prolonged PRN psychotropic use, an outdated warfarin diagnosis, and unused meds. The medical records did not show MD review or documentation of the pharmacist recommendations, and the VPO confirmed there was no evidence the provider reviewed the recommendations for the affected residents.
Failure to Notify Ombudsman of Resident Discharge: The facility did not notify the ombudsman when a resident was discharged. SS stated that ombudsman notifications were not being sent for any planned discharge, and the resident left with a child and personal belongings.
Incomplete ADL Care Plan: A resident with an above-knee amputation, toe loss, and post-stroke hemiplegia/hemiparesis used a wheelchair and required varying levels of assistance with ADLs, including toileting, dressing, personal hygiene, bathing, and transfers. The care plan addressed only a limited ADL focus and bed mobility, but did not include the resident’s needs for several other ADLs, which the CNC confirmed was missing.
Medication cassette labeling did not match a resident’s MAR order. An MA administered atorvastatin from a cassette labeled for bedtime use even though the order was for once-daily dosing at 8 AM, and the MA confirmed the label did not match the resident’s order.
Pureed Meals Prepared Without Following Recipe Instructions: Staff were observed preparing pureed Beef & Broccoli Stir Fry and gravy by adding unmeasured amounts of water and not following the recipe directions, while instant mashed potatoes were also prepared from a bag without measured portions. Two residents receiving pureed diets were affected, including one with difficulty chewing and another with ongoing weight loss and poor intake.
A resident with severe cognitive impairment and full dependence on staff for ADLs was repeatedly observed in soiled clothing with visible food debris and stains, and staff failed to provide necessary personal hygiene care after meals. The DON confirmed that the resident's hygiene needs were not met as required by the care plan.
A resident with diabetes and heart disease developed Stage 2 pressure ulcers, and the facility failed to consistently complete ordered wound care treatments and weekly skin assessments. Staff often skipped dressing changes and assessments, citing reasons such as clean dressings or missed baths, and did not regularly measure or document wound progress. Facility staff confirmed there was no systematic process for monitoring wound healing, resulting in inadequate management of the resident's pressure ulcers.
The facility's kitchen was found to have unsanitary conditions and expired food items, potentially affecting all residents. Observations included debris on shelving, stovetop, and windowsill, and outdated food items in the refrigerator. The Dietary Manager confirmed the issues and the policy of using or discarding food within five days.
The facility failed to maintain a pest-free kitchen environment, as required by the Nebraska Food Code and facility policies. Observations revealed flying insects landing on food preparation surfaces and resident meal plates. Cook-N confirmed the presence of insects and uncertainty about the regular use of industrial bug spray, potentially affecting all 31 residents consuming food from the kitchen.
The facility did not ensure that five staff members completed their initial orientation as required, potentially affecting all 31 residents. Record reviews and an interview confirmed the absence of evidence for completed orientation for a NA, an LPN, another NA, an RN, and another NA. The facility's assessment indicated that training should be completed at orientation, but personnel records showed no such evidence.
The facility failed to act on pharmacist recommendations for four residents, including dose reductions and lab checks, with no evidence of physician follow-up or rationale for inaction.
The facility failed to implement gradual dose reductions (GDR) for psychotropic medications and did not document the rationale for PRN medication use beyond 14 days for several residents. One resident was on multiple psychotropic medications without GDR attempts, despite a PHQ-9 score indicating no depression. Another resident had a PRN Ativan order without a specified duration, and the facility lacked documentation justifying its continued use. Interviews confirmed the absence of necessary evaluations and documentation.
The facility did not ensure that nurse aides completed the required 12 hours of continuing education, affecting 3 out of 5 sampled employees. NA-K completed 3.85 hours, MA-L completed 11.85 hours, and MA-M completed 9.1 hours, falling short of the mandated training. This deficiency was confirmed by the Administrator and had the potential to impact all 31 residents.
The facility failed to notify physicians of significant weight loss for two residents, as required by policy. One resident lost 12.77% of their weight over six months, and another lost 7.54% in one month. The DON confirmed that these significant weight losses were not communicated to the physicians, and no new interventions were implemented.
The facility inaccurately documented a resident's falls with major injury and another resident's medication use in their MDS assessments. One resident was reported to have multiple falls with major injury, but only had one confirmed incident. Another resident was documented as taking an anticoagulant, but was actually on an antiplatelet medication, aspirin.
A resident with severe cognitive impairment and a history of falls did not receive appropriate interventions after multiple fall incidents, as required by the facility's policy. Despite experiencing falls with varying degrees of injury, the care plan lacked new interventions, and existing interventions were deemed inappropriate. The DON confirmed these deficiencies in the facility's response to the resident's falls.
The facility failed to implement fall prevention measures for a resident with severe cognitive impairment by not ensuring the bed was in the lowest position, as required by the care plan. Additionally, another resident with Alzheimer's disease was transported in a wheelchair without footrests, contrary to safety expectations. These deficiencies were confirmed by staff observations and interviews.
A resident with chronic pain and moderately impaired cognition did not have their pain adequately assessed or documented by the facility staff. Despite physician orders and a care plan for pain management, the facility failed to record progress notes for the resident's reported pain levels of 5 or greater on multiple occasions over several months. An interview confirmed the absence of documentation and assessment of the resident's pain complaints.
A facility failed to assess a resident's dialysis access port site daily, as required by their policy. The resident, diagnosed with end-stage renal disease, had no care plan interventions for monitoring the site, and medical records showed no evidence of such assessments. The DON confirmed the expectation for staff to obtain vital signs and document the resident's condition post-dialysis, but this was not done.
A resident was observed dragging their oxygen nasal cannula on the ground, through food debris and dirt, while ambulating. A nurse aide then placed the nasal cannula back into the resident's nose without disinfecting it first, failing to follow proper infection control practices.
A resident with Alzheimer's and severe cognitive impairment was subjected to a privacy breach when a nurse aide checked their brief for incontinence in a commons area, exposing them in front of other residents. The nurse aide confirmed the action and acknowledged that privacy should have been ensured by conducting the check in the resident's room.
The facility failed to provide necessary toileting assistance for two residents with severe cognitive impairments. One resident, with epilepsy and vascular dementia, was not offered assistance from morning until noon, contrary to their care plan. Another resident with Alzheimer's disease was not assisted for over two hours, and their care plan lacked specific toileting frequency instructions. A nurse aide confirmed limited toileting times, and the DON acknowledged the need for two-hourly assistance.
The facility failed to manage weight loss for two residents, leading to a deficiency in nutrition and hydration. One resident experienced significant weight loss without notification to their medical provider or new interventions. Another resident's dietary needs were not met due to outdated care plans and unawareness of dietary orders, resulting in meals that did not align with their restrictions.
The facility failed to submit investigations of falls with major injuries to the state agency within five working days for three residents. The reports were submitted on an outdated template with an incorrect fax number, and there was no evidence of re-attempts to send the reports after initial failures.
A resident with a history of falls did not receive new interventions after a fall, despite facility policy requiring updates to the care plan. Staff interviews confirmed the lack of new interventions, highlighting a deficiency in fall prevention procedures.
Failure to Identify Root Causes and Implement Effective Fall Prevention Interventions
Penalty
Summary
The facility failed to determine root causes of falls and implement appropriate interventions to prevent recurrence for a resident with severe cognitive impairment and a history of falls. The resident, diagnosed with dementia and exhibiting a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment, experienced multiple falls during their stay. Despite the facility's policy requiring incident reports, fall scene investigations, and care plan updates after each fall, there were repeated lapses in updating the care plan with new or revised interventions following several of the resident's falls. On multiple occasions, the resident was found on the floor, sometimes with injuries such as lacerations and skin tears. Root causes identified in fall scene reports included impaired memory, gait imbalance, inappropriate footwear, and issues with physical coordination. However, interventions listed in these reports were not consistently added to the resident's care plan, and in some cases, no new interventions were developed at all. Interviews with facility leadership confirmed that interventions identified at the time of the fall were not always implemented long-term, and there was a lack of follow-through in updating the care plan to reflect new risks or strategies. Additionally, some interventions placed on the care plan were duplicative or ineffective, such as encouraging the use of a call light for a resident who was known not to use it due to cognitive impairment. The facility also failed to consistently determine the root cause of each fall, and in some cases, interventions were delayed or not implemented until months after the initial incident. These actions and inactions resulted in a failure to provide adequate supervision and accident hazard prevention as required by facility policy and regulatory standards.
Expired Foods, Improper Dishwashing Temperatures, and Inadequate Hair Restraint in Kitchen
Penalty
Summary
The facility failed to dispose of expired foods in the dry storage room. During an observation, a jug of Worcestershire sauce was found with an opened-on date of 7/22/2025 and a best-by date of 10/30/2025, several cans of evaporated milk were found with manufacture dates of 4/3/2024 and no expiration date, and 13 cans of sweetened condensed milk were found with expiration dates of 10/4/2025. The Dietary Director confirmed the Worcestershire sauce and sweetened condensed milk were expired and stated the evaporated milk cans expired 12 to 18 months from the manufacture date and should have been disposed of. The facility also failed to ensure proper dishwashing temperatures and hair restraint use in the kitchen. A dietary aide was observed taking soiled dishes into the kitchen, loading them into the dishwasher, and running wash cycles that reached 91 degrees F, 95 degrees F, 111 degrees F, and then 115 degrees F before the machine was adjusted and a tray was rewashed at 131 degrees F; the first two trays were not rewashed. The same dietary aide was observed in the food preparation area with a hat on and a ponytail hanging down the back unrestrained while dishes were being washed and food was being prepared. The Dietary Director confirmed the aide's hair was in a ponytail and not restrained under the hat, and facility policy and the Food Code required hair restraints and a low-temp dishwasher wash temperature of 120 degrees F.
Unqualified Infection Preventionist Assigned
Penalty
Summary
The facility failed to ensure that a qualified infection preventionist was employed to be responsible for the infection prevention and control program. A record review of a Professional Staff document provided by the facility showed that the administrator was serving as the infection preventionist. During an interview, the Administrator confirmed that the administrator was acting in that role despite not meeting the qualifications required by regulation. The Administrator also stated that the Corporate Nurse Consultant had been assisting with the infection control program remotely from another state, which did not meet regulatory requirements.
Nurse Aide Annual Training Deficiency
Penalty
Summary
The facility failed to ensure that 1 of 5 sampled nurse aides completed the required 12 hours of annual ongoing training. A record review of a facility-provided document showed ongoing training hours for Nurse Aide-G between 10/11/24 and 9/26/25, with 20 separate coursework entries totaling 6.7 hours during that period. During an interview on 12/4/25 at 10:27 AM, the Administrator confirmed the facility had not documented any additional ongoing training hours for Nurse Aide-G beyond the 6.7 hours and acknowledged that the nurse aide did not have the required 12 hours.
Failure to Protect Residents from Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from physical and verbal abuse by another resident. The cited deficiency involved Resident 13, who had a diagnosis of dementia with behavioral disturbances and a very low BIMS score indicating severe cognitive impairment. Records showed Resident 13 had a history of agitation, wandering, attempts to take food from another resident’s plate, attempted hitting of staff, and repeated episodes of yelling and threatening behavior toward others. Although the care plan identified some target behaviors, the record also showed no evidence of non-pharmacological interventions for anxiety or agitation prior to 7/4/2025. On 7/3/2025, Resident 13 was reported yelling at Resident 27, handling Resident 27’s electric razor, and then striking Resident 27 several times with a nearby mirror when Resident 27 tried to take the razor back. Resident 27 sustained a skin tear to the face and a skin tear to the right forearm and declined transfer to the ED. The record also showed Resident 13 had previously wandered into other residents’ rooms and had a pattern of aggressive and disruptive behavior before this incident. Additional incidents involved other residents. On 7/16/2025, Resident 13 stepped into Resident 32’s path, argued with the resident, raised fists, and threatened, "you're not gonna be alive tomorrow," before staff separated them. On 8/5/2025, staff found Resident 13 standing over Resident 24 after a roommate reported Resident 24 was being hit; Resident 13 continued making threatening remarks about other residents. On 10/6/2025, Resident 13 threatened another resident during supper, stating the resident had a gun or knife in their pocket and removing a belt buckle from [gender] pants pocket. On 10/16/2025, Resident 13 gently poked Resident 2 with a butter knife at breakfast. The report also noted that after several of these incidents, there was no evidence of additional interventions implemented in the care plan.
Unnecessary PRN Psychotropic Use and Failure to Reassess Continued Need
Penalty
Summary
The facility failed to prevent unnecessary psychotropic medication use by not attempting, implementing, and documenting non-pharmacological interventions before giving a PRN antipsychotic to Resident 13. Resident 13 had dementia with behavioral disturbances, severe cognitive impairment on admission MDS, and a history of intermittent agitation and anxiety noted in hospital documentation before admission. The care plan identified use of an antipsychotic for anxiety and agitation, but the record showed no evidence of non-pharmacological interventions for anxiety or agitation before 7/4/2025. Later interventions included assessing needs such as food, thirst, toileting, comfort, and body positioning, keeping the resident in a room with limited people, and removing the resident from noisy areas, but the record did not show these interventions were in place before the PRN antipsychotic was administered. The facility also failed to ensure PRN antipsychotics were not continued beyond 14 days for Residents 2 and 13. Resident 2 had PRN orders for haloperidol and Seroquel, including a Seroquel order for verbal outbursts related to dementia that had been used multiple times over the review period. Resident 13 had a PRN haloperidol order for severe behavior and agitation with no stop date. In both cases, pharmacy reviews repeatedly noted that CMS guidance limits PRN psychotropics to 14 days and that continued need should be evaluated, but the medical record showed no evidence that the provider evaluated the continued need for these PRN antipsychotics. The facility further failed to ensure PRN psychotropic medications were not continued past 14 days without a documented rationale for Resident 2 and Resident 28. Resident 2 also had PRN Ativan orders for anxiety or shortness of breath and anxiety, and the provider visits documented in the record did not address the PRN psychotropic orders. Resident 28 had PRN lorazepam orders for agitation, including one order that had been in place since 4/30/2024 and another since 9/2/2025. Pharmacy reviews for Resident 28 repeatedly stated PRN psychotropics should be limited to 14 days and evaluated, but the record showed no evidence the physician reviewed those recommendations. During interview, the VPO confirmed the PRN psychotropic medications had been in place beyond 14 days and that there was no evidence of provider re-evaluation or rationale for continuation.
Failure to Investigate Alleged Resident Abuse and Threats
Penalty
Summary
The facility failed to initiate investigations of potential abuse, complete thorough investigations of alleged violations, and maintain documentation of those investigations for 5 residents. The facility’s abuse prevention policy identified the Administrator as the Abuse Prevention Coordinator and stated that designated personnel on duty would begin an investigation by completing a physical assessment, speaking with involved staff, documenting findings, and determining whether the resident could explain the event or participate in the investigation. The policy also stated that all resident-to-resident altercations were reportable incidents. Resident 13 had diagnoses including dementia with behavioral disturbances, a BIMS score of 3/15 indicating severe cognitive impairment, and a history of agitation, anxiety, wandering, attempted taking food from another resident’s plate, and attempted hitting a NA. On 7/3/2025, an incident report documented that Resident 13 yelled at Resident 27, handled Resident 27’s electric razor, struck Resident 27 several times with a mirror, and caused skin tears to the face and right forearm. The facility’s internal investigation included a statement from the nurse on duty, but there was no documentation that any other staff were interviewed, that Resident 13 was interviewed or could not be interviewed, or that a record review was completed. Additional incidents involving Resident 13 were documented but not thoroughly investigated. On 7/16/2025, Resident 13 told Resident 32, “well get up and fight me,” raised their arms and formed fists, and later threatened, “you’re not gonna be alive tomorrow,” yet the internal investigation showed no evidence that staff assessed the statement for abusive or aggressive intent or initiated a timely investigation. On 7/26/2025, Resident 13 told another resident to shut up and made a threat, but again there was no evidence of assessment for abusive or aggressive intent or a timely investigation. On 8/5/2025, Resident 24 was found curled up in bed yelling for help after a roommate reported being hit, and Resident 13 was found standing over Resident 24 while continuing to make threatening remarks; the internal investigation showed no evidence that the nurse or other staff were interviewed, that the residents were interviewed or deemed incapable of interview, or that a record review was completed. On 9/19/2025, Resident 13 told another resident they should “kick the other resident’s ass,” and an interview later recalled the incident, but the report provided no evidence of a completed investigation for that event.
Failure to Document Physician Review of Monthly Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that a licensed pharmacist’s monthly drug regimen review, including review of the medical chart, was followed by physician review and documentation of the identified irregularities and any action taken. In 3 of 5 sampled residents, the medical record did not show that the attending physician reviewed the pharmacist’s recommendations or documented any response to them. The deficiency involved Residents 2, 13, and 28, and the facility census was 29. For Resident 2, the record showed multiple psychotropic and other medication orders, including Ativan, haloperidol, Seroquel, Dulcolax, Tylenol with Codeine #3, and a prior warfarin order. The pharmacist made repeated recommendations in the progress notes, including that the warfarin diagnosis be updated from health maintenance to an appropriate diagnosis, that PRN psychotropics be limited to 14 days and further evaluated, and that Tylenol #3 and Dulcolax soft chews be considered for discontinuation because they had not been used. The resident’s chart contained provider visits noting the resident was stable or had no changes to orders, but there was no evidence the provider reviewed the pharmacy recommendations from May, August, September, or November 2025, and the VPO confirmed this during interview. For Resident 13, who had dementia with behavioral disturbances and severe cognitive impairment with a BIMS score of 3/15, the order summary showed PRN haloperidol intramuscularly for severe behavior and agitation. The pharmacist documented monthly recommendations that PRN psychotropics should be limited to 14 days and continued need should be evaluated. The medical record did not show physician review of the recommendations from September, October, or November 2025, and the VPO confirmed there was no evidence of provider review. For Resident 28, who also had dementia with behavioral disturbance, the order summary showed PRN lorazepam orders for agitation. The pharmacist again documented that PRN psychotropics should be limited to 14 days and evaluated, but the record did not show physician review of the recommendations from July, September, October, or November 2025, and the VPO confirmed there was no evidence of provider review.
Failure to Notify Ombudsman of Resident Discharge
Penalty
Summary
The facility failed to notify the ombudsman of a resident discharge for Resident 37. Record review showed the resident was admitted to the facility on [DATE] and was discharged on 9/26/2025. A progress note dated 9/26/2025 documented that the resident was discharged from the facility and left with their child and personal belongings. During an interview on 12/2/25 at 2:05 PM, Social Services stated that notifications were not being sent to the ombudsman for any resident with a planned discharge and confirmed that the ombudsman had not been notified of Resident 37's discharge.
Incomplete ADL Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for one resident regarding activities of daily living. The resident was admitted with diagnoses including absence of the right leg above the knee, absence of the left toe, and hemiplegia/hemiparesis following a stroke. A significant change MDS dated 11/5/2025 showed the resident used a wheelchair for locomotion and required supervision for eating, upper body dressing, personal hygiene, and bed mobility; partial assistance for bathing and putting on/taking off footwear; and substantial assistance for toileting, lower body dressing, and transfers. The resident’s care plan included a focus area for ADL self-care performance deficit related to amputation of the left lower extremity, initiated on 8/12/2025, with an intervention for bed mobility stating the resident could independently maneuver with the assistance of the grab bar. However, there was no evidence in the care plan of the resident’s needs related to toileting, dressing, personal hygiene, bathing, or transfers. During interview, the Corporate Nurse Consultant confirmed the care plan did not include that information and stated it should contain it.
Medication Cassette Labeled With Incorrect Administration Time
Penalty
Summary
The facility failed to ensure a medication cassette was labeled with the correct administration time for Resident 27. The resident had an order for atorvastatin calcium 80 mg tablet to be given once daily at 8:00 AM, with a start date of 8/6/2025. During observation on 12/2/2025 at 8:00 AM, Medication Aide H prepared Resident 27’s medications, dispensed one tablet from the atorvastatin cassette into a cup with the resident’s other medications, and administered them to the resident, documenting the dose as completed in the MAR. A record review of the atorvastatin cassette showed instructions to take one tablet by mouth once daily at bedtime, which did not match the resident’s order for 8:00 AM administration. Further observation on 12/2/2025 at 8:05 AM showed 12 doses had been administered from the cassette with 2 doses remaining. During interview, Medication Aide H confirmed the resident’s order was for once-daily administration at 8:00 AM and that staff had been administering the medication from the cassette labeled for bedtime use.
Pureed Meals Prepared Without Following Recipe Instructions
Penalty
Summary
The facility failed to ensure nutritive value was maintained for two residents who received pureed meals. Surveyors observed Cook-E preparing pureed Beef & Broccoli Stir Fry and instant mashed potatoes in the kitchen by repeatedly adding unmeasured amounts of water to the gravy and to the pureed meat dish, rather than following the provided recipe instructions. The observation showed the cook pouring all of the brown gravy mix into a measuring cup without leveling it, adding an unmeasured amount of hot water, then adding more water and whisking the gravy multiple times. The cook also pureed the Beef & Broccoli Stir Fry, checked the consistency, and then added an unmeasured amount of water to the food processor before serving it on plates. Resident 24 had difficulty chewing and required a pureed diet. Resident 28 had a physician’s order for pureed texture foods, had ongoing weight loss, and continued to have poor intake, with progress notes documenting intake at 25% or below and continued weight-loss triggers. During observation, Resident 28 ate only a small amount at breakfast and later consumed less than 50% of lunch, which included mashed potatoes and gravy and pureed Beef and Broccoli Stir Fry. The Dietary Director confirmed recipes should be followed, including the pureed Beef & Broccoli Stir Fry recipe, to ensure nutritive value was retained.
Failure to Maintain Personal Hygiene for Dependent Resident
Penalty
Summary
A deficiency was identified when staff failed to provide adequate personal hygiene care for a resident with severe cognitive impairment and full dependence on staff for activities of daily living. The resident, diagnosed with Alzheimer's disease and osteoarthritis, was observed multiple times throughout the day wearing the same soiled clothing, which had visible white flakes, dried fluid stains, and food debris. Additionally, the resident had yellow food debris on the right side of their mouth, and staff were observed only providing cueing during meals rather than direct hygiene assistance. The resident's care plan required staff to provide extensive assistance with personal hygiene due to the resident's self-care deficits. A grievance had previously been filed by the resident's family member regarding the resident's unkempt appearance, and ongoing concerns were expressed about the lack of hygiene care provided. The Director of Nursing confirmed that the resident's clothing and face were dirty and acknowledged that staff should have provided care after meals and changed the resident's clothing when soiled. Despite the resident's documented need for full assistance, observations and interviews indicated that staff did not consistently maintain the resident's personal hygiene.
Failure to Monitor and Treat Pressure Ulcers as Ordered
Penalty
Summary
The facility failed to provide appropriate monitoring and treatment of pressure ulcers for one resident, as required by both facility policy and physician orders. The resident, who had diagnoses of diabetes and heart disease, developed two Stage 2 pressure ulcers after admission. Orders were in place for specific wound care treatments, including scheduled dressing changes, weekly skin assessments, and the use of pressure-reducing devices. However, documentation revealed that these treatments and assessments were not consistently completed as ordered. On multiple occasions, dressing changes and skin assessments were missed, with staff documenting reasons such as the dressing being clean, dry, and intact, or the resident not having a bath that day. Facility policy required comprehensive wound assessments, including measurements and documentation in the medical record, to be completed at least weekly. Review of the resident's records showed that wound measurements and detailed assessments were not consistently performed or documented. Progress notes often lacked information on wound size, stage, and healing progress, and wounds were only measured if the resident was seen by an external wound clinic. The facility did not have a process in place to monitor wound progress internally, relying instead on sporadic documentation tied to bath days. Interviews with facility staff confirmed these practices. The DON acknowledged the absence of a systematic process for monitoring wound progress and stated that wounds were not measured unless the resident was seen by the wound clinic. Another staff member confirmed that skin assessments and dressing changes should occur as ordered, regardless of whether the resident received a bath or if the dressing appeared clean and intact. The lack of consistent monitoring and documentation led to a failure to ensure that the resident's pressure ulcers were properly managed and evaluated for healing.
Sanitation and Food Expiration Issues in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen and ensure that food was used or discarded before their expiration dates, potentially affecting all 31 residents who consumed meals from the kitchen. During an initial kitchen tour, surveyors observed several unsanitary conditions, including gray fuzzy matter and brown and black debris on the metal shelving unit where pots and pans were stored, and a large amount of burned food debris on the stovetop. Additionally, the dishwashing sink had a sanitizer dispenser tube resting inside a pot full of yellowish liquid and food debris, and the windowsill above the sink was covered in brown and gray debris. The floor throughout the kitchen was littered with food debris and dried liquid splashes. The surveyors also found several food items that were past their expiration dates or not properly labeled. An unopened bottle of teriyaki sauce had a best-by date from the previous year, and a bag of biscuits was dated over a week prior. In the walk-in refrigerator, several items, including diced onions, soup, turkey breast, chicken breast, marinara, chopped garlic, and parmesan cheese, were all past their labeled dates. The Dietary Manager confirmed that food items should be used or disposed of within five days of opening or preparing and acknowledged the presence of outdated items and unsanitary conditions in the kitchen.
Pest Control Deficiency in Kitchen
Penalty
Summary
The facility failed to maintain a pest-free environment in the kitchen, as required by the 2017 Nebraska Food Code and the facility's own policies. Observations on September 3, 2024, revealed multiple flying insects in the kitchen, landing on food preparation surfaces, the steamtable, and resident meal plates. These insects were observed at different times throughout the day, indicating a persistent issue. An interview with Cook-N confirmed the presence of flying insects and suggested uncertainty about the regular use of industrial bug spray, which was typically applied at night. This deficiency had the potential to affect all 31 residents who consumed food prepared in the kitchen.
Failure to Complete Initial Staff Orientation
Penalty
Summary
The facility failed to ensure that five out of five sampled employees completed their initial orientation as required by the licensure reference 175 NAC 12-006.04(B)(i). This deficiency was identified through record reviews and an interview, which revealed that the facility did not have evidence of completed initial orientation for a Nurse Aide (NA) - G, a Licensed Practical Nurse (LPN) - H, a Nurse Aide (NA) - I, a Registered Nurse (RN) - B, and a Nurse Aide (NA) - J. The facility's assessment, last updated on 5/19/2024, indicated that training should be completed at orientation, as referenced in the orientation checklist. However, the personnel records provided by the facility showed no evidence of such completion for the aforementioned staff members. An interview with the Administrator confirmed the lack of evidence for the initial orientation completion for these employees. This oversight had the potential to affect all 31 residents residing at the facility.
Failure to Act on Pharmacist Recommendations
Penalty
Summary
The facility failed to follow up on recommendations made by the facility pharmacist during monthly drug regimen reviews for four residents. Resident 6, who was admitted with dementia and anxiety, had several recommendations from the pharmacist, including checking vitamin D and thyroid-stimulating hormone (TSH) levels, and considering gradual dose reductions of olanzapine and sertraline. However, there was no evidence that these recommendations were acted upon or that any rationale was provided for not doing so. Resident 19, admitted with dementia, vitamin D deficiency, hypertension, and urinary incontinence, had a recommendation from the pharmacist to update the diagnosis on their potassium medication order. Despite this, there was no evidence of action taken or rationale provided. Similarly, Resident 27, with a primary diagnosis of Parkinsonism, had a recommendation to discontinue lisinopril due to repeated hypotension, which was not acted upon until an emergency department visit prompted the discontinuation. Resident 14 had multiple recommendations from the pharmacist, including a gradual dose reduction of sertraline and updating lab tests for cholesterol and A1c levels. Again, there was no evidence of physician reviews or actions taken on these recommendations. Interviews with the Director of Nursing and a Nurse Consultant confirmed the lack of follow-up on pharmacist recommendations across these cases.
Failure to Implement GDR and Document PRN Medication Use
Penalty
Summary
The facility staff failed to implement gradual dose reductions (GDR) for psychotropic medications and did not obtain the necessary rationale for the continued use of PRN medications beyond 14 days for certain residents. Specifically, Resident 27 was taking antipsychotic, antianxiety, and antidepressant medications without any attempt at GDR, despite having a PHQ-9 score indicating no depression. The resident's PRN medication orders lacked an end date, and there was no evidence of re-evaluation every 14 days as required. Interviews confirmed the absence of provider attempts at GDR or appropriate documentation for PRN medication continuation. Resident 17 was admitted with diagnoses including delusional disorder and depression and had a PRN Ativan order without a specified duration or stop date. The facility did not have documentation from the physician justifying the extension of the PRN Ativan beyond 14 days. Interviews with facility staff confirmed the lack of evidence for physician documentation regarding the rationale or duration for the PRN medication. Resident 6, who had no current symptoms of depression according to their PHQ-9 score, was also taking multiple psychotropic medications without any attempt at GDR. The resident's medical records did not show any evidence of GDR attempts, and interviews with facility staff confirmed the absence of such attempts. These deficiencies highlight the facility's failure to adhere to policies regarding the management of psychotropic medications, including the necessary evaluations and documentation for GDR and PRN medication use.
Deficiency in Nurse Aide Continuing Education
Penalty
Summary
The facility failed to ensure that nurse aides completed the required 12 hours of continuing education, as mandated by Licensure Reference 175 NAC 12-006.04(B)(ii)(1). This deficiency was identified through record reviews and an interview, affecting 3 out of 5 sampled employees. Specifically, Nurse Aide (NA) - K completed only 3.85 training hours, Medication Aide (MA) - L completed 11.85 training hours, and MA-M completed 9.1 training hours. The facility's assessment, last updated on 5/19/2024, indicated that nurse aides should complete at least 12 hours of training per year. The employee records showed that NA-K was hired on 5/22/23, MA-L on 9/9/22, and MA-M on 9/1/22. An interview with the Administrator confirmed that these employees had not met the required training hours, potentially affecting all 31 residents at the facility.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician of significant weight loss for two residents, as required by their policy. Resident 17 experienced a weight loss of 21 pounds, equating to a 12.77% decrease over six months, which was not communicated to the physician. The Director of Nursing (DON) confirmed that the physician had not been informed of this significant weight loss, despite the facility's policy mandating such notification. Similarly, Resident 21 experienced a 7.54% weight loss in one month, which was also not reported to the physician. The resident's weight loss was documented in the Minimum Data Set (MDS) assessment, but there was no evidence that the primary provider was informed during subsequent visits. The DON acknowledged that the weight loss was significant and should have been verified and communicated to the physician, but no re-weigh was conducted, and no new interventions were implemented.
Inaccurate MDS Documentation for Falls and Medication Use
Penalty
Summary
The facility failed to accurately document falls with major injury for one resident and the use of antiplatelet medication for another resident in their Minimum Data Set (MDS) assessments. For the first resident, the MDS indicated that the resident had experienced two or more falls with major injury since their prior assessment. However, interviews with the MDS Coordinator and the Director of Nursing (DON) confirmed that the resident had only one fall with major injury on a specific date, and no other falls with major injury had occurred since the resident's admission. For the second resident, the MDS inaccurately documented the resident as taking an anticoagulant, while the resident was actually taking an antiplatelet medication, specifically aspirin, as per the resident's Order Summary. The MDS Coordinator confirmed that the MDS should have reflected the use of an antiplatelet medication instead of an anticoagulant. These inaccuracies in the MDS assessments highlight the facility's failure to ensure accurate documentation of residents' medical conditions and treatments.
Failure to Implement Post-Fall Interventions for a Resident
Penalty
Summary
The facility failed to develop appropriate interventions after falls for a resident with severe cognitive impairment, identified as Resident 17. The resident, who was admitted with diagnoses of epilepsy and vascular dementia, experienced multiple falls, including two without injury, two with minor injury, and one with a major injury resulting in a right arm fracture. Despite these incidents, the facility did not place new interventions after falls on specific dates, as required by their Fall Prevention and Response Policy. The care plan for Resident 17 acknowledged a history of falls related to unsteady gait and poor balance, yet it lacked evidence of interventions following falls on two occasions. Additionally, the interventions documented for other falls were deemed inappropriate, as they merely stated the resident's right to refuse care and to fall, without implementing measures to prevent further falls. The Director of Nursing confirmed the absence of appropriate interventions for the resident's falls, highlighting a deficiency in the facility's response to fall incidents.
Failure to Implement Fall Prevention and Wheelchair Safety Measures
Penalty
Summary
The facility failed to implement fall prevention interventions for Resident 17, who was admitted with diagnoses of epilepsy and vascular dementia and had severe cognitive impairment. The resident's care plan, last reviewed on 7/19/2024, indicated a history of multiple falls and required the bed to be in the lowest position when the resident was in bed. However, an observation on 8/29/2024 revealed that the bed was not in the lowest position while the resident was resting, which was confirmed by a nurse aide. Additionally, the facility did not ensure the safety of Resident 13 during wheelchair locomotion. Resident 13, admitted with Alzheimer's disease and severe cognitive impairment, required full assistance for wheelchair locomotion. An observation on 8/28/2024 showed that a nurse aide was pushing the resident in a wheelchair without using footrests, which was confirmed by the aide. The Director of Nursing confirmed that the expectation is for staff to use wheelchair footrests to prevent potential injury.
Failure to Document and Address Resident's Pain Management
Penalty
Summary
The facility staff failed to adequately assess and document the pain management for a resident, identified as Resident 19, who had moderately impaired cognition and chronic pain related to osteoarthritis. The facility's policy on pain assessment and management requires a multidisciplinary approach, including documenting the resident's reported level of pain with sufficient detail. Despite this, the facility did not document progress notes for Resident 19's reported pain levels of 5 or greater on multiple occasions across June, July, August, and September 2024. This lack of documentation occurred despite physician orders to monitor for verbal and non-verbal signs of pain every shift and to complete a pain progress note if the pain scale was scored at 5 or more. Resident 19's care plan included scheduled pain medications and non-pharmacological interventions, with specific orders for Tylenol, Voltaren Gel, and Anusol Cream. However, the facility failed to record any progress notes related to the resident's pain on several dates when the resident reported significant pain levels. An interview with a Nurse Consultant confirmed the absence of pain progress notes and the lack of assessment or addressing of Resident 19's complaints of pain during the specified months. This oversight indicates a failure to adhere to the facility's pain management policy and to provide appropriate pain management for the resident.
Failure to Monitor Dialysis Access Site
Penalty
Summary
The facility failed to assess the dialysis access port site daily for a resident with end-stage renal disease, as required by their policy. The policy, revised in March 2019, mandates daily monitoring of the access site for signs of infection. However, a review of the resident's care plan, which was last reviewed in August 2024, showed no interventions related to assessing the dialysis port site. Additionally, the resident's active physician's orders required a dialysis daily note every Monday, Wednesday, and Friday, but did not specify the details to be documented. A review of the resident's medical records, including Medication Administration Records, Treatment Administration Records, Progress Notes, and practitioners' orders from August to September 2024, revealed no evidence that the facility staff monitored the dialysis access site. An interview with the Director of Nursing confirmed the expectation that the resident's vital signs and weight should be obtained by facility staff, along with a progress note upon the resident's return from dialysis. However, there was no documentation indicating that these assessments were conducted.
Infection Control Lapse in Oxygen Administration
Penalty
Summary
The facility failed to implement proper infection control practices during oxygen administration for a resident. During an observation, a resident was seen ambulating from the dining room to their room while dragging their oxygen nasal cannula on the ground, through food debris and dirt. A nurse aide intervened and placed the nasal cannula back into the resident's nose without disinfecting it first. This action was confirmed in an interview with the nurse aide, who acknowledged the failure to sanitize the nasal cannula before reapplying it.
Resident Privacy Breach During Personal Care
Penalty
Summary
The facility failed to protect the dignity and privacy of a resident during personal care activities. Resident 13, who was admitted with a diagnosis of Alzheimer's disease and had severe cognitive impairment, required moderate assistance for toileting. During an observation, a nurse aide checked Resident 13's brief for incontinence in the commons area by pulling down their pants in the presence of two other residents. This action was confirmed by the nurse aide during an interview, acknowledging that privacy should have been provided by taking the resident back to their room for the check.
Failure to Provide Toileting Assistance for Cognitively Impaired Residents
Penalty
Summary
The facility failed to provide necessary assistance with toileting and incontinence care for two residents, both of whom had severe cognitive impairments and required assistance as per their care plans. Resident 17, admitted with diagnoses of epilepsy and vascular dementia, was observed not being offered assistance to the bathroom from 8:58 AM to 12:14 PM, despite their care plan indicating they should be assisted every two hours and before meals. A nurse aide confirmed that Resident 17 had not been offered toileting assistance since before breakfast, which was against the care plan's requirements. Similarly, Resident 13, diagnosed with Alzheimer's disease, was not assisted with toileting from 10:15 AM to 12:21 PM. The care plan for Resident 13 lacked specific instructions on the frequency of toileting assistance, and a nurse aide revealed that residents were only toileted before breakfast, after lunch, and before dinner. The Director of Nursing confirmed that residents should be assisted with toileting every two hours, indicating a failure to adhere to the expected care standards for these residents.
Failure to Implement Nutritional Interventions for Residents
Penalty
Summary
The facility staff failed to implement interventions to manage weight loss for two residents, leading to a deficiency in providing adequate nutrition and hydration. Resident 21 experienced a significant weight loss of 7.54% in one month, as documented in their Minimum Data Set (MDS) and weight records. Despite this, the resident's primary medical provider was not notified, and no new interventions were put in place to address the weight loss. The care plan for Resident 21 included interventions such as providing liquid protein and monitoring food intake, but these were not effectively implemented or updated in response to the resident's condition. Resident 12, who had diagnoses including Diabetes Mellitus and an open wound, also experienced deficiencies in dietary management. The resident's care plan included a double protein consumption intervention, but there was no corresponding protein supplement order in the physician's records. Additionally, the dietary manager was unaware of the complete dietary orders, leading to inconsistencies in the meals served. Observations revealed that the meals provided did not align with the resident's dietary restrictions, such as low sodium and diabetic diet requirements, as ordered by the wound clinic. Interviews with the Director of Nursing and a Nurse Consultant confirmed that the care plans and dietary orders for both residents were not up to date or reflective of their current needs. The facility's failure to notify medical providers of significant weight changes and to implement appropriate dietary interventions contributed to the deficiency in maintaining the residents' health through adequate nutrition and hydration.
Failure to Report Falls with Major Injuries
Penalty
Summary
The facility failed to submit their investigation of falls with major injuries to the state agency within five working days for three residents. The facility's policy, dated December 2022, mandates that the Administrator, DNS, or Nursing Supervisor ensure that a report is filed, the internal investigation begins immediately, and appropriate reporting takes place. However, the facility did not adhere to this policy. For Resident 1, the facility attempted to fax a 5-page Investigation Report but did not re-attempt after the initial failure. For Resident 2, there was no evidence that the facility attempted to send the report to the state agency. Similarly, for Resident 3, there was no evidence of an attempt to send the report to the state agency. All three reports were submitted on an outdated version of the investigation template containing an incorrect fax number for the state agency. An interview with the Administrator confirmed that the Administrator was responsible for sending investigations to the state agency. The Administrator also confirmed that the fax sheet for Resident 1 was sent to the incorrect fax number listed on the outdated template. This resulted in the failure to report the investigations of falls with major injuries for Residents 1, 2, and 3 to the state agency within the required timeframe.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement interventions to reduce falls for a resident with a history of falls. The resident, admitted with diagnoses including epilepsy, vascular dementia, depression, anxiety, and osteoarthritis, was severely impaired in daily decision-making and required moderate assistance with all Activities of Daily Living. Despite having more than two minor injury falls and more than two non-injury falls since admission, no new interventions were placed after the resident's fall on 1/11/2024. The facility's policy required post-fall documentation, including root-cause analysis and updating the care plan with new interventions, but this was not followed. Interviews with facility staff confirmed the lack of new interventions after the fall. The Registered Nurse (RN) and Social Services Director (SSD) both acknowledged that no new interventions were added to the resident's care plan following the fall. The RN indicated a belief that continuing the same interventions was sufficient, while the SSD confirmed the absence of new interventions in the care plan. This failure to update the care plan and implement new interventions after the fall constitutes a deficiency in the facility's fall prevention and response procedures.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 13 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Chadron
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pioneer Manor Nursing Home | 19.1 mi | ★★★★★ | 4 | 0 |
| Ponderosa Villa | 24 mi | ★★★★★ | 9 | 0 |
| Oglala Sioux Lakota Nursing Home | 28.7 mi | ★★★★★ | 9 | 0 |
| Hemingford Care Center | 36.3 mi | ★★★★★ | 23 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.