Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hillcrest Health & Rehab during CMS and state inspections, most recent first.
Food storage, kitchen sanitation, and food temp monitoring were not maintained. Multiple food items in the fridge and freezer were opened, unlabeled, undated, or not sealed; food splatters and debris were observed on equipment, floors, and surfaces throughout the kitchen; and staff did not check all required holding temps before service. Staff also reused temp probes without sanitizing them between foods, changed gloves without hand hygiene, and placed tongs on a contaminated range handle before using them with food.
The facility’s QAPI process failed to identify multiple survey deficiencies and no plans of action were implemented to address them. The Administrator confirmed that issues involving care plan meetings, advance directives, change-in-condition notification, MDS accuracy, care planning, fluid restrictions, equipment safety, respiratory and dialysis services, medication timing, kitchen sanitation, documentation accuracy, and medication administration practices were not captured through QAPI review.
The facility failed to notify the provider of abnormal blood sugars, medications given outside ordered hold parameters, and an increased AIMS score. A resident had multiple blood glucose readings above the ordered notification threshold with no evidence of MD notification. Three residents received antihypertensive medications when BP or pulse were outside ordered parameters, and the DON confirmed there was no documentation that the provider was notified. Another resident's AIMS score increased, but the record did not show provider notification.
Failure to Hold Quarterly Care Plan Meetings and Invite Residents/Families: The facility did not complete quarterly care plan meetings or document resident/family invitations for 3 residents. One resident was cognitively aware with COPD, DM2, CHF, and PTSD; another had spinal stenosis, HTN, depression, and anxiety with moderate cognitive impairment; and a third had CKD, DM2, CHF, and need for personal care with moderate cognitive impairment. Each resident confirmed not being invited, and the Administrator confirmed the missing meetings and invitations.
Facility staff changed a cognitively intact resident’s code status in the EHR to DNR without obtaining a signed CPR/NO CPR form. The resident’s most recent signed form indicated CPR, the order summary and EHR listed DNR, and both the resident and CCC confirmed the resident was full code and wanted CPR.
Failure to complete recapitulation of stay for a resident admitted with a displaced trimalleolar fracture of the R lower leg and L foot drop. Record review showed no evidence the document was completed before discharge, and the DON stated it was not initiated by social services in the charting system.
A facility inaccurately coded the MDS for two residents. One resident with OSA had TAR and PN documentation showing no CPAP equipment was available, yet the admission MDS coded use of a non-invasive mechanical ventilator. Another resident with dysphagia following a stroke received nutrition and hydration through tube feeding, but the admission MDS undercoded the extent of tube feeding and fluid intake. The DCS stated the facility followed the RAI manual and did not have a policy regarding MDS accuracy.
A facility failed to develop CCPs with measurable interventions for two residents. One resident with seizures had an anticonvulsant order and a documented seizure episode, but the CCP did not address seizure history or care. Another resident’s MDS identified multiple needs, including functional assistance, urinary incontinence and an indwelling catheter, falls, nutrition, hydration, psychotropic use, and pain, but the CCP had no interventions for those areas; the DON and MDSC-P confirmed the plans were not developed.
The facility failed to complete recliner chair safety assessments for two residents at risk for falls. One resident with dementia, weakness, and unsteadiness slid to the floor when an electric recliner tipped forward, and another resident with hemiplegia and moderate cognitive impairment slid out of a recliner after not being able to use the remote; the electric lift chair assessment was not completed for either resident. In a separate event, an oxygen concentrator was left on while the nasal cannula was on the floor, and staff confirmed it should have been turned off.
Failure to Follow Ordered Fluid Restriction: A resident with CHF was ordered a 2,000 mL fluid restriction, but staff exceeded the limit on multiple days and left a water pitcher within reach in the resident’s room and later in the commons area. Staff reported fluids were only verbally communicated and totaled at the end of shift, while the DON confirmed residents on fluid restriction should not have a water pitcher in the room.
Incomplete PAP Orders and Oxygen Settings Not Followed: The facility had missing or incomplete PAP and oxygen orders for several residents with respiratory needs. One resident’s CPAP order did not include settings, another resident had no CPAP order at all, and multiple residents’ oxygen concentrators were observed set at rates that did not match the orders or were not fully specified in the chart. Staff and the DON confirmed the missing or mismatched orders.
A resident who required dialysis had repeated problems with late transport to the dialysis center, resulting in arrival after the scheduled clinic time. The resident, who had CKD stage 4, renal dialysis dependence, mobility impairment, and a wound, reported the issue to staff and the dialysis SW. Facility policy required the facility to coordinate dialysis transportation and meal/snack needs, but staff interviews showed transport was arranged through a CSA and the resident’s dialysis schedule was not consistently met.
Medication Administered Outside Ordered Parameters: The facility failed to ensure that ordered hold parameters were followed for three residents receiving antihypertensive medications. MAR review showed carvedilol, metoprolol, and hydrochlorothiazide were administered when pulse or BP values were below the prescribed limits, and the DON confirmed the doses should not have been given.
Inaccurate CPAP documentation and missing restorative records were cited for two residents. One resident with OSA had a CPAP order, but the TAR showed inconsistent administration entries even though staff confirmed no CPAP machine was ever available. Another resident with CVA, severe cognitive impairment, and left-sided ROM impairment received restorative ROM to the left hand, but the EMR lacked required documentation of the program, participation, assistance, response, and progress.
Infection prevention and control failures occurred during medication administration for two residents. A medication tech administered an injectable medication without gloves or hand hygiene and left a resident’s nasal cannula on the floor while it remained connected to oxygen. In a separate observation, an RN removed gloves and put on new gloves without performing hand hygiene before giving eye drops after insulin administration.
Two residents at risk for pressure ulcers did not receive timely or appropriate interventions, including the use of pressure-relieving devices and specific care plan updates. One resident developed new pressure ulcers without the ordered Roho cushion or air mattress in place, while another was transferred without protective footwear, contributing to ulcer development. Additionally, practitioner-ordered wound care was not consistently provided or documented for a resident with a foot ulcer.
Staff did not consistently wear required masks during a COVID-19 outbreak, failed to implement Enhanced Barrier Precautions for a resident with a chronic wound, and allowed damaged recliners in a common area to remain in use despite being unable to be fully cleaned, as confirmed by direct observation and staff interviews.
The facility did not complete required neurological checks after unwitnessed falls for two residents, including one with significant cognitive impairment and another with mobility issues. Additionally, a resident was not provided with PRN bowel medications or monitored for bowel movements as required by facility policy, despite extended periods without a bowel movement. Staff interviews and documentation confirmed these deficiencies.
Two residents with significant fall risks and physical impairments were not adequately protected from accidents. One resident experienced a fall during an attempted transfer without proper staff assistance or a thorough post-fall investigation, while another resident was repeatedly observed without access to a call light or bell as required by their care plan, leaving them unable to request help for over an hour.
A resident with chronic heart failure and a prosthetic heart valve experienced multiple episodes of low oxygen saturation, with readings documented below facility alert thresholds. Staff failed to consistently notify a nurse or provider of these changes, and critical low readings were not escalated as required by facility policy. The resident was later found unresponsive, and interviews confirmed that protocols for monitoring and responding to changes in condition were not followed.
Two residents with severe cognitive impairment experienced multiple falls due to the facility's failure to ensure fall prevention measures, such as bed and wheelchair alarms, were consistently in place and functioning. Despite care plans indicating the need for alarms, incidents revealed that these interventions were not properly implemented, leading to falls and injuries.
A facility failed to comply with CMS regulations by extending a PRN order for Lorazepam without a rationale and did not identify target behaviors for Quetiapine Fumarate and Lorazepam for a resident. The DON confirmed the absence of a rationale and target behaviors, indicating a lapse in monitoring and managing the resident's conditions.
The facility's MRR Policy lacked specific time frames for each step of the process and did not outline steps for pharmacists when immediate action is required. The DON confirmed the policy was considered complete despite these omissions.
Food Storage, Sanitation, and Temperature Monitoring Failures
Penalty
Summary
Food storage practices in the kitchen were not maintained in accordance with the facility’s policy. During observation with the Dietary Manager, multiple items were found in the Superior 2-door reach-in refrigerator, walk-in refrigerator, and walk-in freezer that were opened, partially wrapped, tied shut, or otherwise not sealed, and several items were not labeled or dated. These included shredded cheese, cheese slices, meat chunks, butter, red chunks in a plastic container, green beans, French fries, a steam pan with an unknown substance, grilled chicken breast filets, country fried beef fritters, and hamburger patties. The Dietary Manager confirmed the items were not labeled, dated, and/or sealed and should have been. The kitchen was also observed to be unclean and unsanitary. Food splatters, debris, and sticky residue were seen on the mixer, the wall behind the mixer, kitchen floors, the exterior of the reach-in refrigerator, the ice machine, the Southbend range, the preparation table shelf, the shelf below the steam table, the floor below the clean side of the dish machine table, and the walk-in refrigerator floor. On a later observation, similar food splatters and debris remained on the mixer, the wall behind it, the kitchen floors, the exterior of the reach-in refrigerator, the Southbend range, the preparation table shelf, and the shelf below the steam table. Food splatters were also seen on the Magnolia Circle kitchen oven and cabinets below the steam table. The Dietary Manager confirmed these areas were not clean and should have been. Food temperature monitoring was incomplete and food was served without all required holding temperatures being checked. Review of the temperature logs showed many meals without cold food holding temperatures recorded, and some meals with no temperatures recorded at all. The logs also did not include columns for final cooking temperatures or mechanically prepared foods. During meal service observations, staff did not check holding temperatures of all foods on the steam table before plating, and one Culinary Server stated there were no more spaces on the log sheets. In addition, temperature probes were used without being sanitized between foods, were wiped with contaminated cloths or napkins, and were not cleaned before reuse. Staff also removed gloves and put on new gloves without handwashing. Tongs were placed on a sticky, contaminated range handle and then used to handle food, allowing the food-contact surfaces of the tongs to touch the contaminated range exterior and handle. The Dietary Manager confirmed staff should have checked food temperatures before serving, sanitized the temperature probe between foods, washed hands between glove changes, and not contaminated the tongs.
QAPI Failed to Identify Multiple Survey Deficiencies
Penalty
Summary
The facility’s QAPI program failed to identify multiple deficiencies cited during the annual survey and did not implement plans of action to identify and correct the deficient practices. Record review of the QAPI policies showed the program was intended to monitor critical aspects of operations, analyze findings, identify areas of opportunity, and implement systemic solutions through quarterly committee meetings and dashboard review. However, the survey findings showed that the QAPI process did not address deficiencies associated with F 553, F 578, F 580, F 628, F 641, F 656, F 684, F 689, F 692, F 695, F 698, F 757, F 812, F 842, and F 880. The Administrator confirmed in interview that these federal deficiencies had not been identified by the QAPI process and that no plans of action were implemented to identify and correct the deficient practices. The cited issues included failure to ensure residents or representatives were invited to care plan meetings, failure to ensure the right to formulate an advance directive, failure to notify the practitioner of changes in condition, failure to complete recapitulation of stay, failure to ensure accuracy of the MDS, and failure to develop a comprehensive care plan related to resident-specific issues. Additional cited deficiencies included failure to follow fluid restriction orders, failure to evaluate equipment for safety, failure to have valid orders for respiratory services, failure to coordinate dialysis services, failure to ensure medications were provided within parameters, failure to maintain food safety and sanitation in the kitchen, failure to ensure documentation was accurate, and failure to ensure proper glove use, equipment placement, and hand hygiene during medication administration. The facility census was 120, and the survey sample size was 51.
Failure to Notify Provider of Abnormal Findings and Medication Errors
Penalty
Summary
The facility failed to notify the provider of multiple resident condition changes and medication administration issues. For Resident 151, blood glucose monitoring orders required notification of the MD for blood sugars less than 70 or greater than 400, yet several blood sugar results were above 400, including 452, 405, 481, 426, 483, 528, and 491, with no evidence the provider was notified. The DON confirmed the elevated values and confirmed there was no documentation of provider notification. The facility also administered medications outside ordered parameters for several residents without evidence of provider notification. Resident 151 received carvedilol on multiple occasions when pulse rates were below the ordered hold parameter of 60, and the DON confirmed the medication should not have been given and that the provider was not notified. Resident 2 received metoprolol succinate when blood pressure and pulse values were outside the ordered hold parameters, and Resident 146 received hydrochlorothiazide on several occasions when systolic blood pressure was below the ordered hold parameter of 110. In each case, the DON confirmed the medication was administered outside parameters and that there was no evidence the provider was notified. The facility also failed to notify the provider of a change in Resident 30's AIMS score. The resident's AIMS score increased from 6 on a prior evaluation to 9 on a later evaluation, but the progress notes and 60-day LTC visit note did not show provider notification or mention of the increased score. The DON and CCC-G confirmed there was no documentation in the electronic health record showing that the provider was notified of the increased AIMS score.
Failure to Hold Quarterly Care Plan Meetings and Invite Residents/Families
Penalty
Summary
The facility failed to ensure comprehensive care plan meetings and resident/family invitations were completed quarterly for 3 of 6 sampled residents. The facility policy stated the interdisciplinary team was responsible for reviewing and updating the care plan at least quarterly, and residents had the right to participate in the planning process and identify individuals to be included. The report also cited Medicare guidance stating care assessments must be completed at least every 90 days, or more often if needs change, with the resident, family, or representative allowed to take part in planning care. Resident 14 had diagnoses including COPD, Type 2 DM with uncontrolled blood sugars, chronic diastolic CHF, and PTSD, and had a BIMS score of 15 indicating cognitive awareness. The last documented care plan meeting was on 04/24/2025, and the progress notes, Clinical - Assessment list, and Client Uploaded Files did not show any subsequent care plan meeting or invitations to the resident or family. Resident 14 confirmed not being invited to a care plan meeting and was unsure whether the family had been invited. The Administrator confirmed the facility was supposed to conduct quarterly care plan meetings and document verbal invitations to residents and phone or email invitations to families in progress notes, and confirmed no care plan meeting or invitation had occurred since 04/24/2025. Resident 130 had diagnoses including spinal stenosis, essential hypertension, depression, and anxiety, with a BIMS score of 12 indicating moderate cognitive impairment. The last care plan meeting documented in progress notes was on 06/25/2025, and there was no documentation of any later meeting or invitations in the progress notes, Clinical - Assessment list, or Client Uploaded Files. Resident 130 stated the resident had never been invited to a care plan meeting. Resident 9 had diagnoses including CKD, Type 2 DM with uncontrolled blood sugars, chronic diastolic CHF, and need for personal care, with a BIMS score of 8 indicating moderate cognitive impairment. The last care plan meeting documented was on 05/28/2025, and there was no documentation of later meetings or invitations in the same record areas. Resident 9 also confirmed not being invited to a care plan meeting, and the Administrator confirmed no care plan meeting or invitation had occurred since 05/28/2025.
Unsigned Code Status Change for Cognitively Intact Resident
Penalty
Summary
Facility staff failed to obtain a signed code status before changing Resident 16’s code status in the electronic health record. The facility’s undated CPR directive policy stated that residents shall indicate in writing their preference regarding resuscitation, that the admitting personnel will explain the CPR/no CPR process, and that a signed CPR/No CPR form will be obtained and copied for physician signature before the updated copy is placed in the resident’s EHR. Resident 16’s MDS showed a BIMS score of 15, indicating cognitive intactness. The record showed the most recent signed CPR/NO CPR form acknowledged CPR, while the order summary and EHR later listed the resident as DNR. During interview, Resident 16 stated being full code, and the CCC confirmed changing the code status to DNR while also confirming that Resident 16 was full code and wanted CPR.
Failure to Complete Recapitulation of Stay
Penalty
Summary
The facility failed to complete a recapitulation of stay for one resident. The resident was admitted on 03/20/2026 with diagnoses of displaced trimalleolar fracture of the right lower leg and foot drop of the left foot, and was discharged on 04/16/2026. Record review of the resident’s admission record, clinical census, and electronic health record, including progress notes, assessments, and scanned documents, showed no evidence that a recapitulation of the resident’s stay was completed. During interview, the DON stated the recapitulation of stay was not completed because the social services department had not initiated the document in the charting system, and confirmed that it should have been completed.
Inaccurate MDS Coding for CPAP and Tube Feeding
Penalty
Summary
The facility failed to accurately code the MDS for two residents. For one resident admitted with obstructive sleep apnea, the TAR documented CPAP as not administered on some days and administered on others, while progress notes stated there was no CPAP equipment available on those dates. The admission MDS, however, coded the resident as receiving a non-invasive mechanical ventilator during the assessment review period. During interview, the MDS Coordinator confirmed the resident never had a CPAP machine available and that the MDS was coded incorrectly; the Director of Clinical Services also stated the facility did not have a policy regarding MDS accuracy and followed the RAI manual. For another resident admitted with dysphagia following cerebral infarction, the order summary showed tube feeding with Osmolite 1.5 four times daily, and oral intake records showed no oral intake documented until later in the stay. The admission MDS coded the resident as receiving 25% or less of total calories through parenteral or tube feeding and as receiving 501 mL per day or less of daily average fluid intake by IV or tube feeding. The DON confirmed the resident received no oral intake until later and received all nutrition and hydration through tube feeding during the MDS assessment review period, and confirmed the admission MDS was coded inaccurately.
Failure to Develop Comprehensive Care Plans for Seizures and Multiple Identified Care Areas
Penalty
Summary
The facility failed to develop comprehensive care plans with measurable objectives and timetables for two residents. For one resident with a diagnosis of seizures, the record showed an admission MDS with severe cognitive impairment, an anticonvulsant medication used daily, and physician orders for levetiracetam 500 mg twice daily for seizures. Progress notes documented a seizure lasting 5 minutes with tremors, twitching, and chewing motions, and the provider directed transfer to the ER by 911. The resident’s undated CCP did not identify seizure activity or history and did not include specific seizure-related care, and the DON confirmed the care plan should have been developed. For another resident, the admission MDS identified multiple care areas requiring a comprehensive care plan, including functional abilities, urinary incontinence and an indwelling catheter, falls, nutritional status, dehydration/fluid maintenance, pressure ulcer/injury risk, psychotropic drug use, and pain. The resident required varying levels of assistance with eating, hygiene, dressing, toileting, bathing, and footwear; had an indwelling urinary catheter; was frequently incontinent of bowel; had a recent fall and a prior fracture related to a fall; was at risk for pressure injury; received antipsychotic and antianxiety medication; and had frequent pain affecting sleep and daily activities. The undated CCP contained no identified interventions for functional abilities, urinary incontinence and catheter care, falls, nutritional status, dehydration/fluid maintenance, psychotropic drug use, or pain, and the MDSC-P confirmed the comprehensive care plan was not developed and should have been.
Missed recliner safety assessments and oxygen concentrator left on
Penalty
Summary
The facility failed to complete recliner chair safety evaluations for two residents who were identified as being at risk for falls. One resident was admitted with lack of coordination, generalized muscle weakness, unsteadiness on feet, and unspecified dementia, and was found to be at risk for falls on admission. That resident attempted to lower the footrest of an electric recliner, the recliner tipped forward, and the resident slid to the floor without injury. Review of the electronic record showed no recliner safety evaluation had been completed, and staff confirmed the evaluation should have been done. The second resident was admitted with hemiplegia and hemiparesis following a cerebral infarction and had moderate cognitive impairment, dependent mobility, and therapy involvement. The resident had a fall risk score indicating risk for falls and had an unwitnessed fall after being found lying in front of the recliner with the Hoyer sling underneath and the recliner upright; the resident stated they could not figure out the recliner remote and slid out. The record showed the electric lift chair assessment was not completed. In a separate event, an oxygen concentrator was observed left on while the nasal cannula was on the floor, and staff confirmed the concentrator should have been shut off before leaving the room.
Failure to Follow Ordered Fluid Restriction
Penalty
Summary
Facility staff failed to follow an ordered 2,000 mL fluid restriction for a resident admitted with chronic diastolic congestive heart failure. The resident’s order, dated 05/08/2026, specified 400 mL with breakfast, lunch, and dinner, with 800 mL remaining for nursing med pass. Facility policy stated that residents on fluid restriction should not have a water pitcher at bedside and that nursing staff were responsible for documenting fluid intakes in the clinical record. Record review showed the resident exceeded the daily fluid restriction on multiple days in May 2026, including by 1,900 mL, 300 mL, 1,300 mL, 250 mL, and 1,000 mL. Observations on 06/03/2026 and 06/04/2026 showed a clear water pitcher within the resident’s reach in the room and later in the commons area, with water marked at approximately 300 mL and then 450 mL. Staff interviews confirmed direct care staff tracked fluids only by verbal communication and end-of-shift totals, did not document the amounts anywhere else, and were unaware the resident had gone over the restriction. The DON confirmed residents with fluid restrictions should not have a water pitcher in the room and acknowledged the restriction had been exceeded on the identified dates.
Incomplete PAP Orders and Oxygen Settings Not Followed
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care when it did not have valid PAP device orders for 2 residents and did not have or follow valid oxygen orders for 3 residents. The deficiency was identified through observation, interview, and record review, and involved residents with respiratory diagnoses including COPD and sleep apnea-related PAP use. Facility policy and referenced clinical guidance stated that oxygen required a physician’s order and that PAP use required a prescription. For one resident with COPD, the clinical physician orders included CPAP use but did not list the machine settings, even though the resident used the PAP device nightly and staff confirmed there were no settings in the order. The same resident also had an oxygen order for 1 liter per minute with CPAP at bedtime, but observations showed the oxygen concentrator set at 2 liters per minute on multiple occasions. RN-C confirmed the concentrator was set higher than ordered, and the DON confirmed there were no other orders beyond those in the chart. For two other residents, oxygen orders were incomplete or not followed as written. One resident had an order for oxygen at 3 liters per minute as needed for shortness of breath at night, but observations and RN-C confirmation showed the concentrator set at 2 liters per minute. Another resident had an order for oxygen for comfort without settings listed, and observations showed the concentrator set at 1.5 liters per minute and later 2 liters per minute; the care plan did not include oxygen interventions. A fourth resident had a CPAP device in the room and used it nightly, but there was no CPAP settings order or cleaning schedule order, and RN-N confirmed those orders were absent.
Delayed Dialysis Transportation Coordination
Penalty
Summary
The facility failed to coordinate meals and transportation for a resident who required dialysis services. The resident was admitted with chronic kidney disease stage 4 with dependence on renal dialysis, muscle weakness with abnormal gait and mobility, and a right lower extremity wound. The resident’s MDS showed a BIMS score of 15, indicating cognitive intactness. The care plan identified the need for dialysis related to renal failure and included interventions related to nutrition and hydration for skin integrity concerns. The facility policy stated that transportation to dialysis would be coordinated by the facility and that care with the dialysis provider would include meal or snack arrangements as needed. The resident reported concerns to staff and the dialysis center social worker that transportation from the nursing facility was late on several occasions, causing arrival after the scheduled 6:15 AM dialysis clinic arrival time. The resident stated the same driver was late and that the care coordinator and social work offices were aware. Observation showed the resident loading into a contracted transport van at 6:17 AM. Staff interviews showed that transportation needs were arranged by a CSA, who confirmed dialysis times with the dialysis facility and then arranged transportation. The CSA stated the dialysis clinic was only a couple of minutes away and that the resident could leave at 6:00 AM and still be on time.
Medication Administered Outside Ordered Parameters
Penalty
Summary
The facility failed to ensure residents were not given medications outside of ordered parameters, resulting in a deficiency for unnecessary drugs. The facility’s Unnecessary Medication Policy stated that each resident’s medication regimen must be free from unnecessary medications and that resident response to medications, including adverse consequences, must be documented. The report identified that the facility had a census of 120 and that 3 of 8 sampled residents received medications when the documented hold parameters were not met. Resident 151 had an order for carvedilol 3.125 mg twice daily for hypertension with instructions to hold for systolic blood pressure less than 90 and pulse less than 60. The MAR showed the medication was administered on multiple dates when the pulse was below 60, including pulses of 59, 56, 57, 53, and 55. Resident 2 had an order for metoprolol succinate ER 25 mg, 0.5 tablet daily for hypertension, to be held for systolic blood pressure less than 90 or pulse less than 60; the MAR showed the medication was given when the pulse was 57. Resident 146 had an order for hydrochlorothiazide 12.5 mg daily for hypertension, to be held if systolic blood pressure was less than 110; the MAR showed the medication was administered on several dates when blood pressure readings were below 110, including 109/70, 105/72, 108/69, 104/70, and 106/70. In interviews, the DON confirmed the medications were administered outside the ordered parameters and should not have been.
Inaccurate CPAP Documentation and Missing Restorative Service Records
Penalty
Summary
The facility failed to accurately document the use of a CPAP device for one resident with obstructive sleep apnea. The resident was admitted with an active CPAP order with home settings, but the Treatment Administration Record showed the CPAP as not administered on three dates and administered on the remaining dates during the review period. Progress notes also documented that no CPAP equipment was available for use on those dates. During interview, the Clinical Care Coordinator confirmed the resident never had a CPAP machine available and that the TAR entries showing the CPAP as administered were not accurate. The facility also failed to document restorative services for another resident with a history of CVA with left-sided hemiplegia, severe cognitive impairment, and range of motion impairment. The resident was observed seated in a wheelchair with a left-hand contracture and later received a restorative session with range of motion to the left hand. However, the electronic medical record did not include documentation of the type of restorative program, duration, resident participation, level of assistance provided, tolerance or response, refusals or barriers, progress toward goals, or monthly or periodic summaries. The DON confirmed the resident received restorative exercises but that there was no documentation of the services provided, and the RNA stated the resident received range of motion to the left hand 1-2 times per week and that there was nowhere to document the services.
Infection Prevention and Control Failures During Medication Administration
Penalty
Summary
The facility failed to apply gloves before administering an injectable medication to Resident 20 and failed to discard the resident’s nasal cannula that was lying on the floor while the oxygen tubing remained connected to a running oxygen concentrator. During the observation, Medication Tech A entered the resident’s room, obtained a blood pressure reading on the resident’s right arm, provided a medication cup, and then administered the injection into the back of the resident’s right arm without completing hand hygiene or applying gloves. The facility’s undated insulin administration competency stated to check the MAR for the injection site, apply gloves, clean the site with an alcohol wipe, and then insert the needle at a 45-degree angle. The facility also failed to perform hand hygiene between removing gloves and putting on new gloves during medication administration for Resident 14. Registered Nurse C performed hand hygiene, donned gloves, entered the resident’s room, and administered insulin. After removing the gloves, RN C applied new gloves without performing hand hygiene before administering the resident’s eye drops. The facility’s Infection Prevention and Control Program dated 01/01/2026 stated that staff should perform hand hygiene before donning and after removing gloves, and RN C confirmed that hand hygiene was not performed between glove changes before giving the eye drops.
Failure to Implement Pressure Ulcer Prevention and Wound Care Interventions
Penalty
Summary
The facility failed to implement appropriate interventions for the prevention of pressure ulcers and did not provide practitioner-ordered wound care for two residents. One resident, who was at moderate to high risk for pressure ulcer development due to limited mobility, incontinence, and cognitive impairment, experienced a decline in skin integrity. Despite worsening Braden Scale scores and the development of a stage 2 pressure ulcer and an unstageable heel ulcer, the care plan was not updated in a timely manner to reflect new interventions. Observations revealed that ordered pressure-relieving devices, such as a Roho cushion and air mattress, were not in place, and heel protectors were only implemented after the heel wound developed. Staff interviews confirmed delays in obtaining and implementing these interventions. Another resident, who had multiple comorbidities and was dependent on staff for transfers and mobility, developed an unstageable pressure ulcer on the left foot related to not wearing appropriate footwear during transfers. The care plan did not include specific interventions addressing the cause of the ulcer, such as the requirement to wear shoes during all transfers. Observations showed that staff continued to transfer the resident using a sit-to-stand lift while the resident wore only socks, and staff interviews confirmed a lack of awareness regarding the need for protective footwear during transfers. The resident also confirmed that staff had not provided instructions to change transfer practices after the ulcer was identified. Additionally, the facility failed to consistently provide and document practitioner-ordered wound care for the resident with the left foot ulcer. Review of treatment records revealed multiple missed wound care treatments on specified dates, and staff interviews confirmed that these treatments were not completed as ordered. The wound nurse acknowledged that wound care was not always documented or performed according to the physician's orders.
Failure to Follow Infection Control Protocols During Outbreak and Inadequate Equipment Maintenance
Penalty
Summary
Staff failed to adhere to the facility's infection prevention and control policies during a COVID-19 outbreak. Despite the facility's policy requiring all staff to wear source control (surgical mask or N-95 respirator) during outbreak status, multiple staff members, including nurse techs, an LPN, and an environmental services tech, were observed in various hallways and resident rooms without masks. This occurred even in areas with confirmed COVID-19 positive residents and in rooms with droplet precautions signage. Interviews with staff and the administrator confirmed that guidance had been provided to wear masks, but compliance was not maintained. The facility also failed to implement Enhanced Barrier Precautions (EBP) for a resident with a chronic wound, as required by policy. The resident had an unstageable pressure ulcer and required EBP, including the use of gowns and gloves during high-contact care and appropriate signage outside the room. Observations revealed that no EBP signage was posted, gowns were not available, and staff, including the wound nurse, did not don gowns during wound care. Staff were observed performing wound care without proper PPE and then moving throughout the facility, and interviews confirmed that EBP was not in place as required. Additionally, six recliners in a commons area had vinyl coverings that were peeling away from the armrests and seats, making them unable to be fully cleaned. The Environmental Services Director confirmed that the damaged chairs could not be properly sanitized, increasing the potential for cross contamination in the shared area.
Failure to Complete Neuro Checks and Bowel Management Interventions
Penalty
Summary
The facility failed to implement required neurological checks following unwitnessed falls for two residents. For one resident with a history of infection, myasthenia gravis, and impaired mobility, neurological checks were ordered after an unwitnessed fall, but several scheduled assessments were missed over multiple days. Documentation confirmed that these checks were not completed as expected, and there was no additional evidence of the assessments being performed. Another resident, who was severely cognitively impaired, required extensive assistance with activities of daily living, and was receiving hospice care, experienced two unwitnessed falls. Record review and staff interviews confirmed that neurological checks were not conducted after either incident, despite facility policy requiring such assessments for unwitnessed falls. Additionally, the facility did not monitor or intervene appropriately for bowel management for the same cognitively impaired resident. Bowel records showed extended periods without a bowel movement, and the Medication Administration Record indicated that no PRN bowel medications were administered during these times. Staff interviews confirmed that the resident should have received PRN bowel medications according to facility policy, but this did not occur.
Failure to Prevent Accidents and Ensure Adequate Supervision for Residents at Risk of Falls
Penalty
Summary
A deficiency was identified regarding the facility's failure to ensure a safe environment free from accident hazards and to provide adequate supervision to prevent accidents for two residents with significant fall risks and physical impairments. One resident, admitted with multiple diagnoses including infection due to a knee prosthesis, bacteremia, myasthenia gravis, essential tremors, and gait abnormalities, was dependent on staff for transfers and had impaired range of motion. Despite these risks, the resident experienced a fall while attempting to transfer from a recliner to bed. Documentation revealed that staff were aware the resident needed assistance and instructed the resident to wait, but upon returning, found the resident on one knee at the bedside. The incident was not fully investigated, as required by facility policy, with no comprehensive documentation, staff statements, or root cause analysis completed. Progress notes did not reflect the fall, and there was no evidence of a formal review during clinical meetings. Another resident, assessed as severely cognitively impaired and at high risk for falls, required extensive assistance with activities of daily living and had a history of multiple falls. The resident's care plan included interventions such as keeping a call light and bell within reach, frequent rounding, and environmental modifications to reduce fall risk. However, multiple observations showed the resident's bell was consistently out of reach, and at times, the call light was not accessible. Staff confirmed the call light was broken and a work order was supposedly placed, but the Environmental Service Director reported no such work order had been submitted. The resident was left without access to a call light or bell for over an hour, contrary to the care plan interventions. These events demonstrate lapses in both the implementation of individualized fall prevention interventions and the facility's investigative processes following incidents. The lack of thorough documentation, failure to ensure assistive devices were within reach, and incomplete post-fall investigation contributed to the deficiencies identified for both residents.
Failure to Evaluate and Respond to Change in Condition for Resident with Low Oxygen Saturation
Penalty
Summary
The facility failed to properly evaluate and respond to a change in condition for a resident with a history of infection related to a hip prosthesis, chronic systolic heart failure, and a prosthetic heart valve. The resident had moderately impaired cognitive function and was being monitored for oxygen saturation, with facility parameters indicating that levels below 90% required attention. Over several days, the resident's oxygen saturation levels fluctuated, with multiple documented readings below the facility's threshold, including a reading as low as 54%. Despite these low readings, there was no physician order for oxygen, and staff did not consistently notify a nurse or provider of the resident's declining oxygen saturation. On one occasion, a nurse aide recorded a critically low oxygen saturation but became busy and failed to report it to the nurse. Other staff members noted low oxygen levels but did not observe respiratory distress and did not escalate the issue appropriately. The situation escalated when dietary staff alerted a registered nurse that the resident was unresponsive, at which point the resident was found without signs of life. Facility policy required detailed observation and provider notification in the event of a change in condition, but this was not followed. Interviews with staff confirmed that expected protocols, such as rechecking oxygen saturation, ensuring oxygen was administered as ordered, and notifying the physician, were not consistently implemented. The failure to recognize and respond to the resident's significant change in condition directly contributed to the deficiency cited in the report.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to implement fall prevention interventions for two residents, leading to multiple incidents of falls. Resident 4, who was admitted with a displaced fracture and severe cognitive impairment, was identified as high risk for falls. Despite having a care plan that included a bed alarm and physical therapy consult, Resident 4 experienced falls on two occasions. On the second incident, the resident was found on the floor with a hip fracture, and it was confirmed that the bed alarm was not functioning as it should have been. Resident 7, also with severe cognitive impairment and dependent for transfers, had a care plan that included alarms on the wheelchair and bed. However, Resident 7 experienced multiple falls, including sliding out of the wheelchair and being found on the floor by the bed. The incidents revealed that the alarms were not consistently in place or functioning, as evidenced by the lack of initialing on the treatment administration record to confirm alarm checks. Interviews with staff, including a Medication Aide and the Director of Nursing, confirmed that the alarms were not in place or functioning during the falls. The Clinical Care Coordinator also acknowledged the absence of functional alarms and the need for staff education on ensuring fall interventions were in place. These deficiencies highlight a failure in the facility's fall prevention measures, leading to repeated falls for the residents involved.
Failure to Provide Rationale and Identify Target Behaviors for Psychotropic Medications
Penalty
Summary
The facility failed to ensure compliance with CMS regulations regarding the use of psychotropic medications for a resident. Specifically, a PRN order for Lorazepam, an antianxiety medication, was extended for 365 days without providing a rationale for its continued use beyond the 14-day limit set by CMS. This was confirmed during an interview with the Director of Nursing, who acknowledged the absence of a rationale for the PRN Lorazepam order. Additionally, the facility did not identify target behaviors for the use of Quetiapine Fumarate, an antipsychotic medication, and Lorazepam for the resident. The orders required monitoring for target behaviors related to the resident's schizoaffective disorder and panic disorder, respectively. However, the Director of Nursing confirmed that target behaviors were not identified for either medication, indicating a failure to properly monitor and manage the resident's conditions as per the prescribed orders.
Deficiency in Medication Regimen Review Policy
Penalty
Summary
The facility failed to ensure that its Medication Regimen Review (MRR) Policy included the required procedural steps, as mandated by licensure reference number 175 NAC 12-006.12(A)(vi). A record review of the facility's MRR policy dated January 1, 2023, revealed that the policy lacked specific time frames for each step of the MRR process. Additionally, the policy did not outline the steps the pharmacist must take when an irregularity requires immediate action. During an interview on December 16, 2024, the Director of Nursing confirmed that the MRR Policy was considered complete as written, despite these omissions.
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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 Bellevue
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hillcrest Country Estates-cottages | 4.6 mi | ★★★★★ | 0 | 0 |
| Omaha Nursing And Rehabilitation Center | 6.1 mi | ★★★★★ | 1 | 0 |
| Hillcrest Shadow Lake Llc | 6.2 mi | ★★★★★ | 4 | 0 |
| St. Joseph Villa Nursing Center | 6.8 mi | ★★★★★ | 28 | 0 |
| Brookestone Of Papillion | 6.9 mi | ★★★★★ | 1 | 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 October 2026) and official state health department websites.