Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Hillcrest Firethorn during CMS and state inspections, most recent first.
Surveyors found that food items in the walk-in freezer and refrigerator were not properly labeled, dated, or covered, and some processed foods were not discarded after the required period. The Dietary Manager confirmed these lapses, which were not in accordance with facility policy or the Nebraska Food Code, potentially affecting all residents.
Two residents were allowed to self-administer medications, including inhalers and nebulizer treatments, without documented assessments of their competency or physician orders as required by facility policy. One resident had an intact cognitive status and the other had moderate cognitive impairment, but neither had the necessary documentation for self-administration. Staff confirmed that these assessments and orders had not been completed.
Three residents were found with medications unsecured in their rooms, including artificial tears, nasal spray, eye drops, antifungal powder, and topical cream. In two cases, there was no completed assessment or physician order for self-administration or to keep medications at bedside, and in another, the medication was not stored in a locked container as required. Staff confirmed that one resident was not capable of self-administration and that medications should not have been left unsecured.
Staff did not consistently use gowns and gloves as required for Enhanced Barrier Precautions during high-contact care activities, such as wound care, catheter care, and resident transfers. In several cases, staff failed to change gloves or perform proper hand hygiene between tasks, and shared equipment was not disinfected after use. These actions were not in accordance with the facility's infection prevention policies and care plans for residents with indwelling devices, wounds, or other risk factors.
The facility failed to follow its bowel management program for a resident, leading to discomfort from unauthorized digital stimulation. Another resident experienced an inadvertent removal of a suprapubic catheter due to a misinterpreted order, resulting in delayed medical attention and additional surgery. These incidents highlight lapses in care protocols and communication within the facility.
A resident's suprapubic catheter was mistakenly removed by an LPN who misread the order. The error was not immediately communicated to the resident's family or healthcare provider, leading to a delay in addressing the medical issue. The facility's policy required notification of significant changes within 24 hours, but the emergent nature of the situation warranted immediate communication, which did not occur.
The facility failed to perform proper hand hygiene during catheter and wound care for a resident with multiple fractures, parkinsonism, chronic kidney disease, and a pressure ulcer. Both an NT and an LPN did not perform hand hygiene after removing soiled gloves and before applying new gloves, and the NT reached into a package of wipes with soiled gloves. Interviews confirmed that hand hygiene should have been performed between glove changes.
The facility kitchen staff failed to label and date opened packages of food and did not dispose of expired food. Additionally, a Dietary Aide was observed engaging in unsanitary practices while prepping room trays, including licking fingers and touching hair without proper hand hygiene. These actions were confirmed by the Dietary Manager as inappropriate.
The facility failed to complete a Level II PASARR for a resident who received new diagnoses of PTSD, Major Depressive Disorder, and Anxiety Disorder. Despite the facility's policy requiring PASRR screenings for changes in diagnosis, the necessary Level II PASARR was not initiated, as confirmed by the Director of Transitions.
A facility failed to update the care plan for a resident with multiple diagnoses and moderate cognitive impairment after a fall resulting in a rib fracture. Despite being identified as at risk for falls, no new interventions were added to the care plan, and staff were unaware of the resident's fall risk.
Improper Food Storage and Labeling in Dietary Services
Penalty
Summary
Surveyors observed multiple instances of improper food storage in the facility's walk-in freezer and refrigerator. Specifically, open boxes of beef patties, chicken patties, chicken fillets, and breakfast potatoes were found in the freezer without labels, dates, or proper sealing, leaving them exposed to air. In the walk-in refrigerator, a serving pan of soup dated 3/16 and a serving pan of rice dated 3/17 were found uncovered or inadequately covered, with the rice appearing dried out. These observations were confirmed by the Dietary Manager, who acknowledged that the items should have been labeled, dated, and sealed according to facility policy. A review of facility policy and the Nebraska Food Code revealed requirements for all food products to be covered, clearly labeled with preparation and expiration dates, and for perishable foods to be discarded after three days. The surveyors found that processed food items were not discarded after the required seven-day period, and food was not stored in accordance with professional standards, creating the potential for foodborne illness. The deficiency had the potential to affect all 56 residents in the facility.
Failure to Assess and Obtain Orders for Resident Self-Administration of Medications
Penalty
Summary
The facility failed to assess two residents for their ability to safely self-administer medications and did not obtain the required physician orders for bedside medication administration. Facility policy requires that residents may self-administer medications only if deemed competent by the nursing team, with a completed assessment and a physician's order documenting the resident's capability. However, for both residents in question, there was no evidence in the medical records of a self-administration assessment or a physician's order permitting self-administration. One resident, admitted with diagnoses including a right lower leg fracture, depression, anxiety, hypertension, and edema, was observed with multiple medications at bedside, including pills, an inhaler, eye drops, a nebulizer, and nasal spray. The resident confirmed self-administration of these medications. The resident's cognitive status was assessed as intact, but no formal assessment or physician order for self-administration was present in the records. Staff interviews confirmed that these steps had not been completed as required. Another resident, admitted with pneumothorax, bronchiectasis, respiratory failure, and anxiety disorder, was observed with a nebulizer and medication at bedside and confirmed self-administration of nebulizer treatments. This resident had moderate cognitive impairment according to the BIMS score. Again, there was no documentation of a self-administration assessment or physician order for self-administration. Staff confirmed that no such orders or assessments were in place for this resident or others on the long-term care side.
Failure to Secure Medications in Locked Compartments
Penalty
Summary
The facility failed to ensure that medications and biologicals were stored in locked compartments as required, resulting in unsecured medications for three residents. Facility policy states that residents may self-administer medications only if deemed competent by the nursing team, with a completed self-administration assessment and a physician order specifying that medications may be kept at bedside. Additionally, all medications for self-administration should be stored in a lockbox issued to the resident. For one resident with intact cognition, artificial tears were found unlabeled and unsecured on the nightstand, and the resident self-administered the drops without a completed self-medication assessment or a physician order permitting the medication to be kept at bedside. Another resident, also with intact cognition, had a bottle of nasal spray on the tray table in the room, which was not secured, although there was a physician order allowing the medication to be kept at bedside and self-administered. However, the medication was not stored in a locked container as required by policy. A third resident, who had moderate cognitive impairment and multiple medical conditions including respiratory failure, heart failure, glaucoma, and diabetes, had multiple medications including eye drops, antifungal powder, and a topical cream found unsecured in the bathroom. There were no physician orders permitting these medications to be kept at bedside or self-administered, and no assessment of the resident's ability to self-administer medications. Staff confirmed that the resident was not capable of self-administration and that the medications should not have been unsecured in the room.
Failure to Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP), specifically the use of gowns and gloves, for several residents requiring such precautions due to the presence of indwelling medical devices, wounds, or other risk factors. Observations revealed that staff did not consistently don gowns and gloves during high-contact resident care activities, such as wound care, catheter care, and transfers, despite facility policies and signage indicating the need for EBP. For example, during peri-care and suprapubic catheter care for a resident with severe cognitive impairment and a suprapubic catheter, staff wore gowns and gloves but failed to clean the lift sling after use, which was then returned to common use without disinfection. In another instance, an LPN providing suprapubic catheter care to a resident with multiple urinary and kidney diagnoses did not change gloves after handling a soiled dressing and before placing hands into a clean water basin, contrary to infection control protocols. The staff member should have performed hand hygiene and donned clean gloves before proceeding with the next step of care, as confirmed by a clinical care coordinator. This lapse in glove use and hand hygiene increased the risk of cross-contamination during the procedure. Additionally, a resident with multiple chronic conditions, including pressure ulcers, colostomy, and urostomy, was observed receiving wound care and assistance with transfers without staff wearing gowns, despite clear care plan instructions and signage for EBP. Staff confirmed that gowns were not worn due to access issues and lack of awareness, and that wound care was performed without first cleaning off old barrier cream. These failures to follow established infection prevention and control policies contributed to the deficiency cited by surveyors.
Failure in Bowel Management and Catheter Care
Penalty
Summary
The facility failed to adhere to its bowel management program for Resident 3, who was subjected to digital stimulation without proper authorization or necessity. Despite having moderate cognitive impairment, Resident 3 expressed discomfort and a preference for using a bedpan while sitting up, which was not honored. The facility's records showed no bowel toileting program or constipation issues for Resident 3, and no bowel medications were administered as needed. Interviews with staff confirmed that digital stimulation was not appropriate for Resident 3, and the facility's policy did not support such an intervention. Additionally, there was no staff education on bowel management or digital stimulation, leading to discomfort and improper care for Resident 3. In another incident, the facility failed to provide prompt medical attention for Resident 1, who had a suprapubic catheter (SP cath) inadvertently removed instead of just the suture. The error occurred due to a misinterpretation of the physician's order by LPN-E, who did not enlarge the order on the computer screen to see the full instructions. This mistake led to Resident 1 experiencing discomfort and requiring a Foley catheter insertion, which was delayed until the family intervened. The facility did not promptly notify the family or the urologist about the error, and the resident had to undergo additional surgery to replace the SP cath, causing further distress and financial burden. The facility's lack of a policy for following provider's orders and the absence of timely communication with the resident's family and healthcare providers contributed to the deficiencies. The staff's failure to recognize and address the removal of the SP cath in a timely manner resulted in unnecessary pain and complications for Resident 1. These incidents highlight significant lapses in the facility's adherence to care protocols and communication standards, leading to adverse outcomes for the residents involved.
Failure to Notify of Significant Change in Resident's Condition
Penalty
Summary
The facility failed to notify the resident's provider and representative of an emergent significant change in the resident's medical condition. Resident 1, who had a history of neuromuscular dysfunction of the bladder, paraplegia, and spinal stenosis, was admitted with a suprapubic catheter. The catheter was inadvertently removed by LPN-E, who misread the order to remove only the suture. This error was not immediately communicated to the resident's family or healthcare provider. The incident occurred when LPN-E, while administering medication, removed the suprapubic catheter instead of just the suture, as per the order. The resident did not question the removal, and LPN-E did not realize the mistake until later. RN-F, who was informed of the removal during a shift change, did not take immediate action to verify the order or notify the appropriate parties. The error was discovered by APRN-D during a routine assessment, who then facilitated communication with the urologist and the resident's family. The facility's administration was notified of the catheter removal, but the resident's family was not informed until they arrived at the facility later that day. The delay in communication and the failure to immediately address the medical error led to the resident experiencing discomfort and requiring additional medical intervention. The facility's policy required notification of significant changes within 24 hours, but the emergent nature of the situation warranted immediate communication, which did not occur.
Failure to Perform Proper Hand Hygiene During Catheter and Wound Care
Penalty
Summary
The facility failed to perform proper hand hygiene during catheter care and wound care for Resident 14, who had multiple fractures, parkinsonism, chronic kidney disease, and an in-house acquired pressure ulcer. During an observation, NT-C and LPN-B did not perform hand hygiene after removing soiled gloves and before applying new gloves. NT-C also reached into a package of incontinence wipes with soiled gloves and did not perform hand hygiene after cleaning the resident's groin and genitalia. LPN-B similarly failed to perform hand hygiene between cleansing the sacral area and applying a clean dressing. Interviews with the CCC-A, ADM, and DON confirmed that hand hygiene should have been performed between glove changes. NT-C admitted to not realizing the proper times for glove removal and hand hygiene, and expressed reluctance to break contact with the resident to use hand sanitizer. The facility's Hand Hygiene Policy, dated 2/23/2022, outlines the necessity of hand hygiene before and after glove use, and between tasks involving different body sites, which was not followed in this instance.
Improper Food Storage and Hand Hygiene Practices
Penalty
Summary
The facility kitchen staff failed to label and date opened packages of food in the walk-in refrigerator and dry storage, and did not dispose of expired food from the walk-in refrigerator. Observations revealed several opened and undated food items, including jalapeno peppers, lemons, dried out carrots, and various other perishable items. Additionally, expired food items such as coleslaw and baby spinach were found in the refrigerator. The dry storage room also contained improperly stored and undated food items, such as fettucine and ziti noodles. The Dietary Manager confirmed these findings and acknowledged that the expired food should not have been available for use. Furthermore, a Dietary Aide was observed engaging in unsanitary practices while prepping room trays for lunch. The aide licked their fingers to separate meal tickets, rubbed their nose with the back of their hand, and touched their hair without performing proper hand hygiene. Despite washing their hands briefly, the aide continued to engage in these unsanitary practices, which were confirmed by the Dietary Manager as inappropriate. These actions were in violation of the Nebraska Food Code, which mandates proper hand hygiene to prevent cross-contamination during food preparation.
Failure to Complete Level II PASARR for Resident with New Diagnoses
Penalty
Summary
The facility failed to ensure a Level II PASARR was completed after Resident 28 received new diagnoses of PTSD, Major Depressive Disorder, and Anxiety Disorder. Resident 28 was admitted with a primary diagnosis of Spinal Stenosis and had a BIMS score of 15, indicating full cognitive function. Initially, the Level I PASARR indicated no mental illness or intellectual disability. However, the new diagnoses required a Level II PASARR, which was not initiated at the time of diagnosis in August 2023. The deficiency was confirmed during an interview with the Director of Transitions, who acknowledged that a Level II PASARR should have been initiated in August 2023 but was not. The facility's policy mandates that an identification screen (PASRR) be completed for changes in diagnosis or condition, which was not adhered to in this case. This oversight was identified during a record review and subsequent interviews, highlighting a lapse in the facility's compliance with federal requirements for PASARR screenings.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to review and revise the baseline care plan for Resident 68 after a fall with a major injury. Resident 68, who was admitted with multiple diagnoses including a ground-level fall, fracture of the second cervical vertebra, and congestive heart failure, exhibited moderately impaired cognition with a BIMS score of 8. Despite being identified as at risk for falls with a score of 10 on the Fall Risk assessment, the resident's Comprehensive Care Plan (CCP) initiated on 3/28/2024 had no focus, goals, or interventions for falls. After a fall on 4/1/2024 resulting in a rib fracture, the Incident Report indicated that the plan of care would be updated with interventions for frequent checks and offering the bathroom. However, a review on 4/9/2024 revealed no new fall interventions were added to the Baseline Care Plan (BCP) or CCP. Interviews with staff, including a Nurse Tech and the Director of Nursing (DON), revealed a lack of awareness and action regarding the resident's fall risk and the necessary updates to the care plan. The facility's policy on Fall Risk Management and Comprehensive Care Planning mandates that care plans be reviewed and updated as the resident's condition changes, but this was not adhered to in Resident 68's case. The failure to update the care plan after the fall with a major injury indicates a significant lapse in following established protocols for resident safety and care planning.
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What surveyors actually found near you
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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.
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Nursing homes near Lincoln
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Holmes Lake Rehabilitation & Care Center | 2.4 mi | ★★★★★ | 10 | 0 |
| Emerald Nursing & Rehab Brookside Llc | 2.9 mi | ★★★★★ | 27 | 0 |
| St. Jane De Chantal | 3 mi | ★★★★★ | 27 | 0 |
| Southlake Village Rehabilitation & Care Center | 3.1 mi | ★★★★★ | 8 | 0 |
| Eastmont | 3.2 mi | ★★★★★ | 6 | 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.