Below 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 Health & Rehab during CMS and state inspections, most recent first.
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.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 379 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | ★★★★★ | 3 | 0 |
| Hillcrest Shadow Lake Llc | 6.2 mi | ★★★★★ | 4 | 0 |
| St. Joseph Villa Nursing Center | 6.8 mi | ★★★★★ | 27 | 0 |
| Brookestone Of Papillion | 6.9 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Hillcrest Health & Rehab.
100% money-back within 48 hours.
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.