How many inspection deficiencies does Crest View Care Center have?

Crest View Care Center has 27 deficiencies from recent inspections. None are at the Immediate Jeopardy level.

What are the staffing levels at Crest View Care Center?

Crest View Care Center has a two-star staffing rating from CMS with 0.48 RN hours per resident per day. This rating is based on registered nurse (RN), licensed practical nurse (LPN), and nurse aide staffing hours.

Where is Crest View Care Center located?

Crest View Care Center is located in Chadron, NE. It is a Medicare and Medicaid certified skilled nursing facility.

How many beds does Crest View Care Center have?

Crest View Care Center has 70 certified beds.

Who owns Crest View Care Center?

Crest View Care Center is a for profit - limited liability company facility and is part of the LANTIS ENTERPRISES chain.

What questions should families ask when visiting Crest View Care Center?

Families visiting Crest View Care Center should ask about staff retention and training programs. Also ask to speak with current residents or families, tour during mealtime, and request a copy of the most recent inspection report.

How does Crest View Care Center compare to other nursing homes?

Crest View Care Center has a 1-star overall rating, which is below average compared to other nursing homes in NE. Families should carefully review inspection findings and consider alternatives.

Crest View Care Center

Name: Crest View Care Center
Address: 420 Gordon Avenue, Chadron, NE, 69337, US
Telephone: (308) 432-3355
Rating: 1.0

420 Gordon Avenue, Chadron, NE 69337 · (308) 432-3355

For profit - Limited Liability company 70 Beds LANTIS ENTERPRISES Data: November 2025

Trust Grade

35/100

#141 of 177 in NE

Share this report:

Crest View Care Center nursing home in Chadron, NE - Photo 1 of 2

Crest View Care Center nursing home in Chadron, NE - Photo 2 of 2

Photo by Google Street View

View 360° on Google Maps

Last Inspection: September 2024

Within standard 12-15 month inspection cycle. Federal law requires annual inspections.

Overview

Crest View Care Center has received a Trust Grade of F, indicating significant concerns about the quality of care provided. It ranks #141 out of 177 nursing homes in Nebraska, placing it in the bottom half of facilities in the state, although it is the best option in Dawes County. The facility is currently improving, with a decrease in reported issues from 18 in 2024 to just 2 in 2025. Staffing is a weakness, with a rating of 2 out of 5 stars and a turnover rate of 63%, which is higher than the state average. While there have been no fines reported, several concerning issues were noted during inspections, including unsanitary kitchen conditions and the presence of insects, which could pose health risks to residents.

Trust Score: F
In Nebraska: #141/177
Safety Record: Low Risk
Inspections: Getting Better
Staff Stability: 63% turnover. Above average. Higher turnover means staff may not know residents' routines.
Penalties: No fines on record. Clean compliance history, better than most Nebraska facilities.
Skilled Nurses: Each resident gets only 28 minutes of Registered Nurse (RN) attention daily — below average for Nebraska. Fewer RN minutes means fewer trained eyes watching for problems.
Violations: 27 deficiencies on record. Higher than average. Multiple issues found across inspections.

★☆☆☆☆

1.0

Overall Rating

★★☆☆☆

2.0

Staff Levels

★★☆☆☆

2.0

Care Quality

★☆☆☆☆

1.0

Inspection Score

↔

Stable

2024: 18 issues

2025: 2 issues

The Good

Full Sprinkler Coverage · Fire safety systems throughout facility
No fines on record

Facility shows strength in fire safety.

The Bad

1-Star Overall Rating

Below Nebraska average (2.9)

Significant quality concerns identified by CMS

Staff Turnover: 63%

17pts above Nebraska avg (46%)

Frequent staff changes - ask about care continuity

Chain: LANTIS ENTERPRISES

Part of a multi-facility chain

Ask about local staffing decisions and management

Staff turnover is elevated (63%)

15 points above Nebraska average of 48%

The Ugly 27 deficiencies on record

Feb 2025 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Licensure Reference Number 175 NAC 12-006.09(H) Based on observations, interview, and record review, the facility failed to provide services to maintain the personal hygiene for 1 (Resident 3) of 4 sampled residents. The facility identified a census of 30. Findings are: A record review of an admission Record indicated the facility admitted Resident 3 on 6/8/2023 with diagnoses of Alzheimer's disease (a brain disorder that causes memory loss and other cognitive decline) and osteoarthritis (a chronic joint disease that causes pain and stiffness). A record review of Resident 3's quarterly Minimum Data Set (MDS- a standardized assessment tool used to evaluate the health of residents in nursing homes) with an Assessment Reference Date of 2/6/2025 indicated Resident 3 had a Brief Interview for Mental Status (BIMS- a structured evaluation aimed at evaluating aspects of cognition in elderly patients) score of 3/15, which indicated Resident 3 had severe cognitive impairment. The MDS also revealed Resident 3 was fully dependent on staff for personal hygiene and dressing. A record review of Resident 3's Care Plan revealed a focus area, initiated on 6/15/2023, revealed Resident 3 had an Activities of Daily Living (ADL) self-care performance deficit related to Alzheimer's disease progression with interventions for staff to provide extensive assistance for personal hygiene. A record review of the facility's Grievance Tracking Log revealed a grievance was received on 6/18/2024 from Resident 3's family member regarding Resident 3's face and clothing having been unkempt. It also revealed the grievance was resolved on 6/18/2024 by having staff provide care to Resident 3 and later staff education was provided. An observation on 2/24/2025 at 11:05 AM revealed Resident 3 had been sitting in the common's area. Resident 3 had been wearing a dark navy tee-shirt and grey sweatpants. Resident 3's tee-shirt had been scattered throughout with white flakes of an unidentified substance, several areas of dried fluids spots, and crusted area of food debris on the left shoulder sleeve. Resident 3's sweatpants also had several spots of dried fluids and food debris. An observation on 2/24/2025 at 1:00 PM revealed Resident 3 to be sitting in the dining room. Resident 3 continued to have on the same tee-shirt and sweatpants with dried fluid stains and food debris. An observation on 2/24/2025 at 2:55 PM revealed Resident 3 had returned to sitting in the commons area. Resident 3 continued to have on the same tee-shirt and sweatpants with dried fluid stains and food debris. Resident 3 also had yellow food debris on the right side of their mouth. An observation of Resident 3 on 2/24/2025 at 1:00 PM revealed Resident 3 to be sitting in the dining room eating. Staff were noted to be providing cueing to Resident 3. Resident 3 clothing continues to have food debris and stains of dried fluids on their shirt and pants. An interview on 2/24/2024 at 2:10 PM with Resident 3's family member confirmed the family member had filed a grievance in June 2024 regarding Resident 3 being unclean. Resident 3's family member said the facility did provide care to restore Resident 3's hygiene and improvements were made but did not last long. Resident 3's family member revealed ongoing concerns of lack of hygiene care being provided. Resident 3's family member revealed Resident 3's face and clothing are always dirty when the family member visits at least twice a week. An interview on 2/24/2025 at 3:00 PM with the Director of Nursing (DON) confirmed Resident 3's clothing and face were dirty and needed to be cared for. The DON revealed expectations that staff should have provided cares to wash Resident 3 after the meal and should have changed Resident 3's clothing when assisting with toileting every two hours if the clothing was found to be dirty.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Pressure Ulcer Prevention (Tag F0686)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Licensure Reference 175 NAC 12-006.09(H)(iii)(2) Based on record reviews and interviews, the facility failed to provide monitoring of pressure ulcers (a localized injury to the skin and underlying tissue caused by prolonged pressure on a specific area of the body, often occurring over bony prominences like the heels, hips, or tailbone, leading to tissue damage and potential open sores if left untreated; this typically happens in people who are immobile or confined to a bed or wheelchair for extended periods) and treatments for the pressure ulcers as ordered for 1 (Resident 1) of 2 sampled residents. The facility identified a census of 30. Findings are: A record review of a facility policy Skin Program Policy with a last revised date of March 2019 revealed in the policy statement that care, and services would be provided to promote the healing of pressure ulcers that are present. The policy revealed procedures to complete a comprehensive wound assessment including site, stage, size, appearance of the wound bed, undermining, depth, drainage, and status of peri-wound tissue and the use of a pressure ulcer monitor tool at least weekly for monitoring. The policy also included direction that the comprehensive wound assessments were to be placed in the resident's medical record. In addition, the policy revealed treatment including cleansing, debriding, and dressing changes were to be provided as ordered. A record review of an article from The National Institute of Health, titled Wound Dressings from 1/23/2024 indicated that nurses should adhere to the dressing change schedule to re-evaluate the wounds to ensure that the wound bed is vascularized (has blood flow), has viable tissue, and is infection-free. A record review of an admission Record indicated the facility admitted Resident 1 on 1/11/2020 with diagnoses of diabetes and heart disease. A record review of Resident 1's annual Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing home staff identify health problems) with an Assessment Reference Date (ARD) of 12/18/2024 revealed Resident 1 had two Stage 2 (wounds that are open and have partial thickness loss of the skin) pressure ulcers that were not present upon admission with treatments including pressure reducing devices for Resident 1's chair and bed, repositioning program, nutritional intervention, pressure ulcer care, and application of ointment or medication. A record review of Resident 1's Care Plan revealed a focus area, last revised on 6/26/2024, for Resident 1's pressure ulcer development due to immobility. Interventions included to provide treatments as ordered and monitor for effectiveness. On 1/18/2024, an additional focus area was revised to reflect Resident 1's potential for impaired skin integrity with an intervention to assess the resident for skin breakdown each bath day. A record review of Resident 1's Order Summary with active orders date as of 2/25/2025 revealed the following orders: - Change mepilex (an absorbent foam dressing) on bath days and as needed every Wednesday on dayshift with a start date of 5/1/2024. - Cleanse upper buttock wounds with wound cleanser, then apply Optifoam every 72 hours or as needed if soiled with an active start date of 12/7/2024. - Nurse to complete a weekly skin assessment and document a skin/wound progress note every Wednesday on day shift with a start date of 1/18/2023. A record review of Resident 1's Treatment Administration Record (TAR) for December 2024 revealed an order to cleanse upper buttock wounds with wound cleanser then apply an Optifoam dressing was documented as not completed on 12/16/2024 with a reasoning of Other/See Progress Note. A record review of Resident 1's Progress Note from 12/16/2024 revealed the order to cleanse upper buttock wounds with wound cleanser, then apply an Optifoam every 72 hours was documented as not completed with a reason of dressing I clean/dry intact, therefore dressing not changed now. A record review of Resident 1's TAR for February 2025 revealed Resident 1's order for the nurse to complete a weekly skin assessment was documented as not completed on 2/5/2025 with a reasoning of Other/See Progress Note. A record review of Resident 1's Progress Notes from 2/5/2025 at 6:41 PM revealed the order for the nurse to complete a weekly skin assessment was not completed with reason of resident had no bath today, therefore no skin assessment completed. An additional record review of Resident 1's TAR for February 2025 revealed Resident 1's order to change mepilex on bath days and as needed was documented as not completed on 2/5/2025 with a reasoning of Other/See Progress Note. A record review of Resident 1's Progress Notes from 2/5/2025 at 9:53 AM revealed the order to change the mepilex dressing on bath days and needed was not completed with a reason of dressing clean/dry/intact, therefore not changed now. An additional record review of Resident 1's TAR for February 2025 revealed Resident 1's for the nurse to complete a weekly skin assessment had not been documented as completed on 2/19/2025. A record review of Resident 1's Progress Notes from 2/19/2025 at 5:52 PM revealed the order for a weekly skin assessment was not completed with a reason of resident had no bath today. An additional record review of Resident 1's TAR for February 2025 revealed Resident 1's order to change mepilex on bath days and as needed was documented as not completed on 2/19/2025 with a reasoning of Other/See Progress Note. A record review of Resident 1's Progress Notes from 2/19/2025 at 6:31 PM revealed the order for change mepilex on bath days and as needed was not completed with reason of area open to area, no dressing in place. A record review of Resident 1's Progress Notes from 10/2/2024 to 2/20/2024 revealed the following documented skin assessments: - 10/2/2024: Resident 1 Resident continues to have open area to right buttock, measures approximately 0.8cm X 0.7cm. - 10/13/2024: Resident 1 has two small open areas on her right buttocks. Has 2 small 1cm long and 0.5cm long. - 10/19/2024: Resident 1's open area on right buttock measured 1.75 cm (L) X 0.25 cm (W) and had no other open areas. - 10/22/2024: Resident 1 has multiple unmeasurable open areas on bilateral buttocks and sacrum. - 11/2/2024: Resident 1 has 4 small wounds on buttocks and sacrum. Wounds superficial, no drainage noted from sites. - 12/4/2024: Resident 1 has 4 small open skin areas on upper buttocks, toward center, each wound measures less than 0.5 cm. Wounds cleansed with wound cleanser and an Opti foam applied. No drainage/bleeding observed. - 12/7/2024: Resident 1's sacrum has 6-8 small open areas, 0.5 CM circles. Area is close to [their] rectum. - 12/11/2024: Resident 1 continues to have small open areas on sacrum. - 12/13/2024: Resident 1 continues with open skin areas near sacral area, wounds cleansed with wound cleanser and Optifoam dressing applied. No drainage or surrounding redness of open skin areas. - 12/18/2024: Resident 1 has wound on bilateral bilateral buttocks remains red and raised.12/25/2024: Resident 1 continues to have small open areas on sacrum. With redness and small amount of clear light red drainage at the site. - 12/28/2024: Resident 1 continues to have small open areas on sacrum. Wounds cleaned with wound cleanser and covered with mepilex. With small amount of redness at the site. - 1/8/2024: Resident 1 Continues to have have superficial open areas on sacrum. Covered with optifoam. - 1/15/2024: Resident 1 continues to have open areas on sacrum. Wound covered with Optifoam. Denies pain. No surrounding redness. - 1/22/2025: Resident 1 has small open areas in sacrum. Covered with mepilex. - 1/29/2025: Resident had a bath, continues with small open skin areas near sacrum, optifoam applied. - 2/12/2025: Revealed a skin noted continues with healing open skin areas on coccyx area. Opti-foam dressing applied. No bleeding/drainage. - 2/20/2025: Resident 1 has area over [their] right upper buttocks that needed an opti-foam for protection. Has 4-5 scattered small circles that are not healed yet. Applied opti-foam on areas for protection from urine and BM (bowel movement). An interview on 2/24/2024 at 3:00 PM with the Director of Nursing revealed the facility does not have a process in place for monitoring wound progress to see if it is improving or not. Wounds are only measured if the resident receives care by the Wound Clinic and measured there, otherwise, the staff do not measure the wounds. The nurses are to place a progress note of skin assessment with the resident's bath. An interview on 2/25/2025 at 12:00 PM with MDS-B revealed skin assessments should be completed even if a resident does not receive a bath and wound dressing changes should be changed as ordered regardless of if the dressing is clean, dry, and intact. The MDS-B also revealed pressure ulcers should be re-evaluated weekly to monitor progress including measurements. MDS-B confirmed Resident 1's progress note did not reflect the monitoring of Resident 1's pressure ulcer status.

Sept 2024 16 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Licensure Reference 175 NAC 12-006.05(S) Based on observation, interview, and record review; the facility failed to protect resident dignity and right to privacy by ensuring privacy during personal cares for 1 (Resident 13) of 4 sampled residents. The facility identified a census of 31. Findings are: A record review of a facility policy Resident Rights Policy with a last revised date of November 2019, under section 8. Privacy and Confidentiality, indicated the resident has a right to personal privacy during personal cares. A record review of an admission Record indicated the facility admitted Resident 13 on 6/8/2023 with a diagnosis of Alzheimer's disease. A record review of Resident 13's quarterly Minimum Data Set (MDS, a comprehensive assessment that includes medical, psychosocial, cognitive, and functional status to assist with developing care plans for individual residents) with an Assessment Reference Date (ARD) of 8/6/2024 revealed Resident 13 had a Brief Interview for Mental Status score of 3/15, which indicated Resident 13 had severe cognitive impairment. The MDS also indicated Resident 13 required moderate assistance for toileting. An observation on 9/3/2024 at 11:39 AM revealed Resident 13 was in the commons area with two other residents present. Nurse Aide (NA)-C checked Resident 13's brief by pulling down their pants. An interview on 9/3/2024 at 12:21 with NA-C confirmed NA-C had checked Resident 13's brief to see if Resident 13 was incontinent in the commons area by pulling down their pants. NA-C confirmed NA-C should have taken Resident 13 back to their room and provided privacy to check Resident 13 for incontinence.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Notification of Changes (Tag F0580)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Licensure Reference 175 NAC 12-006.04(F)(i)(5) Based on interviews and record reviews, the facility failed to notify the physician of significant weight loss for 2 (Resident 17 and 21) of 2 sampled residents. The facility identified a census of 31. Findings are: A. A record review of a facility policy Nutrition Unplanned Weight Loss Clinical Policy with a last revised date of March 2019 revealed a significant weight loss is 10% in six months. Under section Recording Weights and Follow-Up, the policy revealed nursing will notify the MD of the weight change. A record review of Resident 17's Vitals revealed Resident 17 weighed 164.5 pounds on 2/6/2024 and on 8/6/2024 Resident 17's weight was 143.5 pounds, which was a loss of 21 pounds or 12.77% loss since the weight on 2/6/2024. A record review of Resident 17's medical record did not reveal any evidence that Resident 17's physician was aware of the significant weight loss. An interview on 9/3/2024 at 2:24 PM with the Director of Nursing (DON) confirmed Resident 17's physician had not been notified of Resident 17's significant weight loss. The DON confirmed the physician should have been notified of Resident 17's significant weight loss. B. A record review of a facility policy Nutrition Unplanned Weight Loss Clinical Policy with a last revised date of March 2019 revealed a 5% weight loss in one month was significant. Under section Recording Weights and Follow-Up, the policy revealed nursing would notify the MD (the resident's medical provider) of the weight change. A record review of Resident 21's Minimum Data Set (MDS), a federally mandated comprehensive assessment tool used for care planning, dated 8/6/24 revealed that Resident 21 had a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months and was not on a prescribed weight loss program. A record review of Resident 21's weights revealed that on 7/8/2024, the resident weighed 99.5 pounds and on 8/6/2024, the resident weighed 92 pounds which was a 7.54 % loss in one month. A record review of a scanned document in Resident 21's electronic health record (EHR) revealed Resident 21 was seen by their primary provider on 8/6/24 for their 60-day visit. The provider wrote that there were no new orders. There was no evidence in the provider visit documentation that the provider had been made aware of the resident's significant weight loss. A record review of a scanned document in Resident 21's EHR revealed Resident 21 was seen by their primary provider on 8/9/24 due to the resident not feeling well. There was no evidence in the provider visit documentation that the provider had been made aware of the resident's significant weight loss. An interview on 9/4/24 at 9:05 AM with the Director of Nursing (DON) confirmed that Resident 21's primary provider had not been notified of their significant weight loss and there had been no new interventions put into place to mitigate Resident 21's weight loss. An interview on 9/4/24 at 11:05 AM with the DON revealed that the DON had weighed Resident 21 that day and the resident's weight was 97 pounds. The DON stated that Resident 21's weight documented in August 2024 had to have been incorrect. The DON confirm Resident 21's documented weight at the beginning of August 2024 was a significant weight loss from the prior month's weight and had been identified as such but there was no re-weigh done at the time to verify the loss, no physician notification of the loss, and no new interventions had been put into place.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Assessment Accuracy (Tag F0641)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. A record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual indicated to code aspirin under antiplatelet medication and warfarin or heparin under anticoagulant if the resident had taken within 7 days of the assessment. A record review of Resident 6's MDS with a date of 8/6/2024 in Section N indicated Resident 6 had been taking an anticoagulant and was not marked for taking an antiplatelet. A record review of Resident 6's Order Summary with an active order date of 7/30/2024 revealed Resident 6 had been taking aspirin once a day. There was no evidence Resident 6 had been taking warfarin or heparin. A telephone interview on 8/29/2024 at 1:15 PM with the MDS Coordinator confirmed that Resident 6's MDS, dated [DATE], should have reflected Resident 6 had been taking an antiplatelet medication and not an anticoagulant. Licensure Reference Number 175 NAC 12-006.09(B) Based on record review and interview, the facility failed to accurately document falls with major injury for 1 (Resident 27) of 12 sampled residents and to accurately document antiplatelet use for 1 (Resident 6) of 12 sampled residents in their Minimum Data Set (MDS), a federally mandated comprehensive assessment tool used for care planning. The facility census was 31. The Findings Are: A. A record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, a document published by the Centers for Medicare & Medicaid Services (CMS) to facilitate accurate and effective resident assessment practices in long-term care facilities, revealed that major injuries were those that resulted in bone fractures, joint dislocations, closed head injuries with altered consciousness, and subdural hematomas. A record review of Resident 27's MDS, dated [DATE] revealed in Section J that Resident 27 had had two or more falls with major injury since their prior MDS assessment. A telephone interview on 9/4/24 at 12:27 PM with the MDS Coordinator confirmed that Resident 27's MDS dated [DATE] did indicate that the resident had two or more falls with major injury since their prior MDS assessment. An interview on 9/4/24 at 12:20 PM with the Director of Nursing (DON) confirmed Resident 27 did have one fall with major injury on 2/22/24 but there had been no other falls with major injury since Resident 27 was admitted to the facility.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0657 (Tag F0657)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Based on record reviews and interview, the facility failed to develop interventions after falls for 1 (Resident 17) of 2 sampled residents. The facility identified a census of 31. Findings are: A record review of a facility policy Fall Prevention and Response Policy with a last revised date of October 2022 revealed post fall documentation included placing a new intervention after each fall. A record review of an admission Record indicated the facility admitted Resident 17 on 8/17/2022 with diagnoses of epilepsy and vascular dementia. A record review of Resident 17's quarterly Minimum Data Set (MDS, a comprehensive assessment that includes medical, psychosocial, cognitive, and functional status to assist with developing care plans for individual residents) with an Assessment Reference Date (ARD) of 7/9/2024 indicated Resident 17 had severe cognitive impairment. The MDS also revealed Resident 17 had two falls without injury, two falls with minor injury, and one fall with major injury. A record review of Resident 17's Progress Notes with a date of 3/2/2024 indicated Resident 17 had an unwitnessed fall and was complaining of right wrist pain. Resident 17 was sent to the Emergency Department where it was determined Resident 17 had a right arm fracture. A record review of Resident 17's Progress Notes with a date of 10/26/2023 indicated Resident 17 had been attempting to stand up and had fallen without injury. A record review of Resident 17's Progress Notes with a date of 9/18/2024 indicated Resident had been found on the floor twice within an hour with injuries of abrasion to left knee and ankle. A record review of Resident 17's Progress Notes with a date of 9/17/2024 indicated Resident 17 had an unwitnessed fall in their bathroom without injuries observed. A record review of Resident 17's Progress Notes with a date of 9/14/2023 indicated Resident 17 had fallen in their room without injury. A record review of Resident 17's Care Plan indicated Resident 17 had a history of falls related to unsteady gait and poor balance. There was no evidence of interventions placed after falls on 9/17/2023 or 10/26/2023. An intervention for Resident 17's fall on 9/14/2023 stated Resident has the right to refuse cares and has the right to fall, resident has been educated of risks vs. benefits of refusing cares and assistance. An intervention for Resident 17's fall on 9/17/2023 stated Resident has right to fall. This is agreed upon by provider and family due to resident refusal to follow any interventions in place. An interview on 9/3/2024 at 4:04 PM with the Director of Nursing (DON) confirmed no interventions were placed for Resident 17's fall on 9/17/2023 or 10/26/2023. The DON also confirmed the interventions for Resident 17's fall on 9/14/2023 and 9/18/2023 were not appropriate interventions to prevent additional falls for Resident 17.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Licensure Reference 175 NAC 12- 006.09(H)(i)(3) Based on observations, interviews, and record reviews; the facility failed to provide assistance with toileting and incontinence care for 2 (Resident 13 and 17) of 2 sampled residents. The facility identified a census of 31. Findings are: A. A record review of a facility policy ADL Assistance Provided Per Care Plan with a revision date of September 2022 revealed incontinent residents shall be checked in accordance with their care plan. A record review of an admission Record indicated the facility admitted Resident 17 on 8/17/2022 with diagnoses of epilepsy and vascular dementia. A record review of Resident 17's quarterly Minimum Data Set (MDS, a comprehensive assessment that includes medical, psychosocial, cognitive, and functional status to assist with developing care plans for individual residents) with an Assessment Reference Date (ARD) of 7/9/2024 indicated Resident 17 had severe cognitive impairment. The MDS also indicated Resident 17 required extensive assistance with toileting. A record review of Resident 17's Care Plan with a last review date of 7/19/2024, under the fall section, revealed an intervention to offer assistance to the bathroom every two hours and offer assistance to the bathroom before meals. A continuous observation on 9/3/2024 from 8:58 AM to 12:14 PM revealed Resident 17 had not been offered assistance to the bathroom. An observation on 9/3/2024 at 12:14 PM revealed Nurse Aide (NA) -E assist Resident 17 from the commons area to the dining room without offer assistance to the bathroom. An interview on 9/3/2024 at 12:15 PM with NA-E confirmed Resident 17 had not been offered assistance with toileting since before breakfast and also confirmed Resident 17 should have been offered toileting at least before their meal. B. A record review of an admission Record indicated the facility admitted Resident 13 on 6/8/2023 with a diagnosis of Alzheimer's disease. A record review of Resident 13's quarterly MDS with an ARD of 8/6/2024 revealed Resident 13 had a Brief Interview for Mental Status score of 3/15, which indicated Resident 13 had severe cognitive impairment. The MDS also indicated Resident 13 required moderate assistance for toileting. A record review of Resident 13's Care Plan with a last reviewed date of 8/9/2024 revealed no evidence of how frequent to offer Resident 13 with toileting. A continuous observation on 9/3/2024 from 10:15 AM to 12:21 PM revealed Resident 13 had not been assisted with toileting. An interview on 9/3/2024 at 12:21 PM with NA-C revealed NA-C only toilets residents before breakfast, after lunch, and before dinner. An interview on 9/3/2024 at 1:50 PM with the Director of Nursing confirmed residents should be assisted with toileting every two hours.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Licensure Reference 175 NAC 12- 006.09(I) Based on observations, interviews, and record reviews; the facility failed to ensure fall interventions were being implemented to prevent falls for 1 resident (Resident 17) and ensure safety during wheelchair locomotion with the use of footrests to prevent the potential for injury for 1 resident (Resident 13). The sample size was 3. The facility identified a census of 31. Findings are: A. A record review of a facility policy Fall Prevention and Response Policy with a last revised date of October 2022 indicated minimizing the risk for falls included to implement interventions to prevent falls. A record review of an admission Record indicated the facility admitted Resident 17 on 8/17/2022 with diagnoses of epilepsy and vascular dementia. A record review of Resident 17's quarterly Minimum Data Set (MDS, a comprehensive assessment that includes medical, psychosocial, cognitive, and functional status to assist with developing care plans for individual residents) with an Assessment Reference Date (ARD) of 7/9/2024 indicated Resident 17 had severe cognitive impairment. A record review of Resident 17's Care Plan with a last review date of 7/19/2024, under the fall section, indicated Resident 17 had a history of multiple falls. Interventions included to ensure bed was in the lowest position at all times when Resident 17 was in bed. An observation on 8/29/2024 at 12:35 PM revealed Resident 17 had been resting in bed. Resident 17's bed was not in the lowest position. An interview on 8/29/2024 at 12:48 PM with Nurse Aide (NA) - E confirmed the bed was not in the lowest position. B. A record review of an admission Record indicated the facility admitted Resident 13 on 6/8/2023 with a diagnosis of Alzheimer's disease. A record review of Resident 13's quarterly MDS with an ARD of 8/6/2024 revealed Resident 13 had a Brief Interview for Mental Status score of 3/15, which indicated Resident 13 had severe cognitive impairment. The MDS also revealed Resident 13 required full assistance for wheelchair locomotion. An observation on 8/28/2024 at 2:20 PM revealed NA-F had been pushing Resident 13 in their wheelchair from the commons area down to their room without the use of footrests. An interview on 8/28/2024 at 2:24 with NA-F confirmed NA-F did not use the footrests during locomotion in the wheelchair for Resident 13. An interview on 8/29/2024 at 1:25 PM with the Director of Nursing confirmed the expectation is for staff to use wheelchair footrests when transporting residents in their wheelchairs for safety and to prevent the potential for injury.

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0692 (Tag F0692)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

B. A record review of Resident 12's quarterly MDS) with an Assessment Reference Date of 6/12/24, Section I revealed Resident 12 had diagnoses of Diabetes Mellitus, an open wound on the left lower leg, and lymphedema. A record review of Resident 12's physician orders indicated one order in the Diet category which read, CCD, Consistent Carbohydrate diet Regular texture. A record review of Resident 12's physician orders revealed the following additional orders: - Resident needs to monitor sodium intake every shift, dated 8/5/24. - Resident to follow diabetic diet, dated 6/7/24. - Decrease sodium in diet (no hot dogs, ham, sausage, or bacon), dated 5/29/24. - Diet needs no fruit, sweets, no CARBs (potatoes), no pasta, rice bread. Low sodium and diabetic diet, dated 4/25/24. A record review of Resident 12's document titled, Physician Visit/Communication, dated 8/5/24 from the wound clinic, includes the new order, Resident needs to monitor sodium intake. A record review of Resident 12's care plan last revised 6/7/24 revealed the intervention, Double protein consumption. A record review of Resident 12's physician orders did not reveal a protein supplement order. An interview on 9/03/24 at 3:22 PM with the Dietary Manager (DM) revealed the diet on record for Resident 12 in Dieting Manager, a program used by the kitchen staff to access diet orders was, CCD Consistent carb diet, regular texture. The DM confirmed they were not aware of any other diet orders or recommendations in place for Resident 12. An observation on 08/29/24 at 12:34 PM revealed Resident 12 was in the dining room for lunch. The food served to the resident was mechanical soft stir-fried beef and broccoli with rice and pureed mandarin orange/pineapple mixture. A record review of Resident 12's printed meal ticket for the lunch meal on 8/29/24 indicated Resident 12's diet was CCD consistent carbohydrate, diet texture regular. Supplemental notes on the meal ticket included, no kool-aid, no sauces/gravies; no bread products or breaded meat; no sweets; ground food. An observation on 9/4/24 at 12:25 PM revealed Nurse aide (NA)-C was assisting Resident 12 to eat altered texture beef stroganoff over pasta, ground brussel sprouts, and chocolate ice cream. Ranch dressing was mixed with the stroganoff and vegetable. An interview was conducted with the Director of Nursing (DON) on 9/3/24 at 2:50 PM. During the interview the DON confirmed the additional diet orders for a low sodium diet were ordered by the wound clinic, and the diet served did not match those recommendations. An interview with Nurse Consultant-A (NC-A) on 09/04/24 at 12:20 PM confirmed Resident 12's care plan was not up to date in all areas and did not reflect the resident's current status or dietary recommendations. NC-A confirmed the physician orders from the wound clinic were not reflected in the primary diet order. Licensure Reference Number 175 NAC 12-006.09(J) Licensure Reference Number 175 NAC 12-006.09(J)(i)(1) Based on observations, record review and interview; the facility staff failed to implement interventions to manage weight loss for 2 (Resident 12 and 21) of 3 sampled residents. The facility staff identified a census of 31. The Findings Are: A. A record review of a facility policy Nutrition Unplanned Weight Loss Clinical Policy with a last revised date of March 2019 revealed a 5% weight loss in one month was significant. Under section Recording Weights and Follow-Up, the policy revealed nursing would notify the MD (the resident's medical provider) of the weight change. The policy also revealed in the Treatment/Management section that the staff and physician would identify pertinent interventions based on identified causes and overall resident condition, prognosis, and treatment wishes. A record review of Resident 21's Minimum Data Set (MDS), a federally mandated comprehensive assessment tool used for care planning, dated 8/6/24 revealed that Resident 21 had a weight loss of 5% or more in the last month or loss of 10% or more in the last 6 months and was not on a prescribed weight loss program. A record review of Resident 21's weights revealed on 7/8/2024, the resident weighed 99.5 pounds and on 8/6/2024, the resident weighed 92 pounds which was a 7.54 % loss in one month. A record review of Resident 21's progress note dated 8/14/24 by the Registered Dietitian (RD) revealed the resident had some weight loss in the prior 30 days, that the resident's current diet seemed to be appropriate, and that the RD recommended to continue with the liquid protein order and with fortifying foods at all meals. A record review of Resident 21's physician's orders revealed the following: -An order dated 11/28/2022 that stated the resident was to receive a consistent carbohydrate diet (CCD) with regular textures and consistency. This order also stated, Fortified Foods Program. -An order dated 3/1/2024 that stated to give the resident 30 milliliters (ML) of Protein Oral Liquid by mouth one time a day. A record review of Resident 21's care plan, which had a last review date of 8/14/2024, revealed the following nutritional interventions: -Provide and serve supplements as ordered: 30 ML of liquid protein 1 time per day. This intervention was dated 8/14/2024. -Provide, serve diet as ordered. Monitor intake and record every meal. This intervention was dated 8/14/2024. -Current diet ordered: CCD, regular texture, regular consistency. This intervention was dated 11/30/2022. -I want staff to honor my food preferences. This intervention was dated 11/30/2022. -Staff to monitor and record my foods/fluids daily. This intervention was dated 11/30/2022. -Staff will obtain weight as scheduled. This intervention was dated 6/7/2023. An interview on 9/4/24 at 9:05 AM with the Director of Nursing (DON) confirmed that Resident 21's primary provider had not been notified of their significant weight loss and there had been no new interventions put into place to mitigate Resident 21's weight loss.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0697 (Tag F0697)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Licensure Reference Number 175 NAC 12-006.09(H) Based on record review and interview, the facility staff failed to assess 1 (Resident 19) of 2 sampled resident's pain. The facility census was 31. The Findings Are: A record review of facility policy Pain Assessment and Management Policy with revision date of June 2021 revealed pain management is a multidisciplinary care process that includes assessing the potential for pain, effectively recognizing the presence of pain, identifying the characteristics of pain, addressing the underlying causes of the pain, developing and implementing approaches to pain management, identifying and using specific strategies for different levels and sources of pain, monitoring for the effectiveness of interventions, and modifying approaches as necessary. The policy also states to document the resident's reported level of pain with adequate detail (i.e., enough information to gauge the status of pain and the effectiveness of interventions for pain) as necessary and in accordance with the pain management program. A record review of Resident 19's Minimum Data Set (MDS), a federally mandated comprehensive assessment tool used for care planning, dated 6/18/24 revealed Resident 19 had a Brief Interview for Mental Status (BIMS) score of 10/15, which indicated the resident had moderately impaired cognition. The MDS also revealed Resident 19 had diagnoses of arthritis and hemorrhoids and had been receiving scheduled pain medications as well as non-pharmacological pain interventions. A record review of Resident 19's care plan, which had a last reviewed date of 7/17/2024, revealed Resident 19 had chronic pain related to osteoarthritis (osteoarthritis occurs when the flexible, protective tissue at the ends of bones, called cartilage, wears down). The care plan stated the facility was to monitor and record the resident's pain characteristics: quality (e.g., sharp, burning); severity (1 to 10 scale); anatomical location; onset; duration (e.g., continuous, intermittent); aggravating factors; and relieving factors. A record review of Resident 19's physician's orders, printed on 9/3/24, revealed the following pain-related orders: -An order for Tylenol Extra Strength 500 milligram (MG) tablet, give 1,000 MG three times a day for knee pain. -An order for Voltaren Gel 1 % (a topical non-steroidal anti-inflammatory gel used for pain relief), apply 2 grams (GM) to upper extremities and 4 GM to lower extremities four times a day. -An order for Anusol Cream (a medication used to treat minor pain, itching, swelling, and discomfort due to hemorrhoids), apply to rectum three times a day. -An order of Pain Monitoring: Monitor for verbal and/or non-verbal signs of pain every shift. If the pain scale is scored at 5 or more, complete a pain progress note. A record review of Resident 19's Medication Administration Record (MAR) for June 2024 revealed that Resident 19 had rated their pain at a 5 or greater when the staff conducted their day shift pain monitoring on June 1st, 2nd, 5th, 6th, 11th, 19th, and 29th. A record review of Resident 19's progress notes for the month of June 2024 revealed no evidence of a progress note being documented related to Resident 19's reported pain on June 1st, 2nd, 5th, 6th, 11th, 19th, or 29th and the response to pain management interventions. A record review of Resident 19's MAR for July 2024 revealed that Resident 19 had rated their pain at a 5 or greater when the staff conducted their day shift pain monitoring on July 12th, 14th, 17th, 26th, and 31st. The resident also rated their pain at a 5 or greater during their evening shift pain monitoring on July 31st. A record review of Resident 19's progress notes for the month of July 2024 revealed no evidence of a progress note being documented related to Resident 19's reported pain on July 12th, 14th, 17th, 26th, or 31st and the residents response to pain management interventions. A record review of Resident 19's MAR for August 2024 revealed that Resident 19 had rated their pain at a 5 or greater when the staff conducted their day shift pain monitoring on August 14th, 15th, 23rd, and 28th. A record review of Resident 19's progress notes for the month of August 2024 revealed no evidence of a progress note being documented related to Resident 19's reported pain on August 14th, 15th, 23rd, or 28th and the residents response to pain management interventions. A record review of Resident 19's MAR for September 2024, through the 4th of the month revealed that Resident 19 had rated their pain at a 5 or greater when the staff conducted their day shift pain monitoring on September 3rd. A record review of Resident 19's progress notes for the month of September 2024 revealed no evidence of a progress note being documented related to Resident 19's reported pain on September 3rd and the residents response to pain management interventions. An interview on 9/4/24 at 2:28 PM with Nurse Consultant (NC)-A confirmed that there were no pain progress notes documented for Resident 19 and there was no evidence that Resident 19's complaints of pain that had been identified in the pain monitoring on their MAR during the months of June, July, August, and September 2024 had been assessed or addressed by the facility staff.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0698 (Tag F0698)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Licensure Reference Number 175 NAC 12-006.09(H) Based on record review and interviews, the facility failed to assess 1 (Resident 25) of 1 sampled resident's dialysis access port site daily. The facility census was 31. The Findings Are: A record review of a facility policy Dialysis with revision date of March 2019 revealed that the facility was to monitor the resident's access site for signs or infection at least daily. A record review of Resident 25's Minimum Data Set (MDS), a federally mandated comprehensive assessment tool used for care planning, dated 5/23/24 revealed Resident 25 had a diagnosis of end stage renal disease and was receiving dialysis (a treatment that removes waste and extra fluid from the blood when the kidneys are no longer functioning properly). A record review of Resident 25's care plan, with a last reviewed date of 8/26/24 revealed Resident 25 was receiving dialysis three times per week. There were no interventions in the care plan related to assessing Resident 25's dialysis port site. A record review of Resident 25's active physician's orders revealed an order stating, Dialysis daily note every Monday, Wednesday and Friday upon return. The order did not specify what information was to be documented in the notes. Record review of Resident 25 medical record that included, Medication Administration Records, Treatment Administration records, Progress Notes and practitioners orders from 8/02/2024 through 9/02/2024 revealed there were no indications the facility staff were monitoring Resident 25's dialysis access site. An interview on 9/3/24 at 4:27 PM with the Director of Nursing (DON) confirmed Resident 25 had a dialysis port site, not a fistula, and revealed the DON expected Resident 25's vital signs and weight to be obtained by facility staff, as well as a progress note that Resident 25 had returned the facility and how (gender) is, upon the resident's return to facility following dialysis.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Infection Control (Tag F0880)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Licensure Reference 175 NAC 12-006.18(B) Based on observation, interview, and record review; the facility failed to ensure infection control practices were implemented for oxygen administration for 1 (Resident 6) of 1 sampled residents. The facility identified a census of 31. Findings are: A record review of 1st Class Medical's document The Importance of Changing Your Nasal Cannula with a date of 10/2/2018 indicated to disinfect oxygen nasal cannulas use an alcohol wipe then allow to dry to prevent the potential for bacteria buildup and infections. An observation on 9/3/2024 at 10:24 AM revealed Resident 3 had been ambulating from the dining room and down the hallway to their room. Resident 3 had been dragging their oxygen's nasal cannula on the ground during ambulation, dragging it through food debris and dirt. Further observation s revealed Nurse Aide (NA)-C intervened and placed the nasal cannula back in Resident 3's nose without first disinfecting it. An interview on 9/3/2024 at 10:28 with NA-C confirmed NA-C did not sanitize the nasal cannula before applying back into Resident 3's nose and should have.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Drug Regimen Review (Tag F0756)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** D. A record review of Resident 14's Progress Notes, dated 8/30/2024 revealed a monthly medication regimen review completed by the pharmacist with a recommendation of a gradual dose reduction of the resident's sertraline (an antidepressant medication). A record review of Resident 14's Progress Notes, dated 6/30/2024 revealed a monthly medication regimen review completed by the pharmacist with the statement, Recommend updating labs - cholesterol and A1c. A record review of Resident 14's Progress Notes, dated 5/31/2024 revealed a monthly medication regimen review completed by the pharmacist with the statement, Recommend drawing yearly cholesterol. A record review of Resident 14's Progress Notes, dated 4/30/2024 revealed a monthly medication regimen review completed by the pharmacist with the statement, Recommend checking A1c. A record review of Resident 14's Progress Notes, dated 3/31/2024 revealed a monthly medication regimen review completed by the pharmacist with the statement, Please add diagnosis to Bumex. Interview on 9/3/24 at 8:55 AM with Nurse Consultant-A (NC-A), revealed the facility had no evidence of physician reviews of the monthly medication reviews or GDRs for Resident 14. Licensure Reference Number 175 NAC 12-006.12(A)(vi) Based on record review and interview; the facility staff failed follow up on recommendations by the facility pharmacist and failed to obtain the rational for dosage reductions for 4 (Resident 6, 14, 19 and 27) of 5 sampled residents. The facility staff identified a census of 31. Findings are: A. A record review of an admission Record indicated the facility admitted Resident 6 on 6/17/2022 with diagnoses of Dementia and anxiety. A record review of Resident 6's Progress Notes with a date of 5/31/2024 revealed a monthly medication regimen review completed by the pharmacist with recommendation to check a vitamin D level. A record review of Resident 6's Progress Notes with a date of 3/31/2024 revealed a monthly medication regimen review completed by the pharmacist with a recommendation to recheck a thyroid-stimulating hormone (TSH) level due to a levothyroxine (thyroid medication) dose change on 1/29/2024. A record review of Resident 6's Progress Notes with a date of 2/29/2024 revealed a monthly medication regimen review completed by the pharmacist with a recommendation to consider a gradual dose reduction of Resident 6's olanzapine( a antipsychotic medication). A record review of Resident 6's Progress Notes with a date of 11/30/2023 revealed a monthly medication regimen review completed by the pharmacist with a recommendation to consider a gradual dose reduction of Resident 6's sertraline ( a antidepressant medication). A record review of Resident 6's Progress Notes with a date of 10/31/2023 revealed a monthly medication regimen review completed by the pharmacist with recommendation to check a TSH level. An interview on 8/29/2024 at 11:43 AM with the Director of Nursing (DON) revealed the DON had not received any physician responses to recommendation made by the pharmacist during their monthly medication regimen reviews in the last six months the DON had been employed by the facility. An interview on 9/3/2024 at 8:55 AM with Nurse Consultant (NC) - A revealed the facility had no evidence the provider acted upon or had provided rationale for not acting upon pharmacist recommendations made during the monthly medication regimen reviews. B. A record review of Resident 19's admission Record revealed Resident 19 was admitted to the facility on [DATE] with admission diagnoses of dementia, vitamin D deficiency, essential (primary) hypertension (elevated blood pressure), and urinary incontinence. A record review of Resident 19's progress note dated 6/30/24 by the pharmacist revealed a recommendation to update the diagnosis on the resident's Potassium medication order from primary hypertension to an appropriate diagnosis. A record review of Resident 19's physician's orders revealed an order for Potassium Chloride Extended Release (ER) capsule, 10 milliequivalents (mEq) once a day for Essential (primary) Hypertension. The order had a start date of 9/6/23. An interview on 8/29/24 at 11:43 AM with the Director of Nursing (DON) revealed the DON had not received any physician responses to recommendations made by the pharmacist during their monthly medication regimen reviews in the prior 6 months. An interview on 9/3/24 at 8:55 AM with Nurse Consultant (NC)-A confirmed the facility had no evidence of Resident 19's provider acting upon or providing rationale for not acting upon pharmacist recommendations made during the monthly medication regimen reviews. C. A record review of Resident 27's admission Record revealed Resident 27 was admitted to the facility on [DATE] with a primary diagnosis of Parkinsonism (Parkinsonism is a broad term comprising a clinical syndrome and presenting with various neurodegenerative diseases, which manifest with motor symptoms such as rigidity, tremors, bradykinesia, and unstable posture, leading to profound gait impairment). A record review of Resident 27's progress note dated 1/31/24 by the pharmacist revealed a recommendation to discontinue the resident's lisinopril (a medication used to treat elevated blood pressures) due to the resident having repeated hypotension (low blood pressure). A record review of Resident 27's medical records revealed a scanned emergency department visit document. This document revealed Resident 27 was seen in the emergency department on 3/29/24 due to confusion and a low blood pressure and that the resident's lisinopril order was discontinued during this visit. An interview on 8/29/24 at 11:43 AM with the Director of Nursing (DON) revealed the DON had not received any physician responses to recommendations made by the pharmacist during their monthly medication regimen reviews in the prior 6 months. An interview on 9/3/24 at 8:55 AM with Nurse Consultant (NC)-A confirmed the facility had no evidence of Resident 27's provider acting upon or providing rationale for not acting upon pharmacist recommendations made during the monthly medication regimen reviews.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Medication Errors (Tag F0758)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

C. A record review of an admission Record indicated the facility admitted Resident 17 on 8/19/2021 with diagnoses of delusional disorder, depression, anxiety, and alcohol abuse. A record review of Resident 17's Order Summary with a date of 9/3/2024 revealed an order for PRN Ativan with a start date of 5/3/2024. The order did not include a duration or stop date. A record review of Resident 17's medical record revealed no evidence of physician documentation of a rationale or duration to extend Resident 17's PRN Ativan beyond 14 days. An interview on 9/3/2024 at 8:57 AM with NC-A confirmed the facility had no evidence Resident 17's physician had documented a rationale or duration to extend Resident 17's PRN Ativan beyond 14 days. D. A record review of Resident 6's MDS with a date of 8/6/2024 revealed Resident 6 had a PHQ-9 score of 0/27, which indicated Resident 6 had no current symptoms of depression. The MDS also revealed Resident 6 had been taking an antipsychotic, antianxiety, and antidepressant and that the physician had not attempted a GDR. A record review of Resident 6's Order Summary revealed the following orders: -Bupropion (an antidepressant medication) for anxiety. This order had a start date of 1/18/2023 and did not have an end date or duration indicated. -Olanzapine (an antipsychotic) for Dementia. This order had a start date of 2/21/2023 and did not have an end date or duration indicated. -Sertraline (an antidepressant) for anxiety. This order had a start date of 1/18/2023 and did not have an end date or duration indicated. A record review of Resident 6's medical record revealed no evidence of a GDR being attempted for Resident 6's psychotropic medications. An interview on 9/3/24 at 8:55 AM with Nurse Consultant (NC)-A revealed the facility had no evidence of Resident 6's physician having attempted a GDR. Licensure Reference Number 175 NAC 12-006.09 Based on record review and interview; the facility staff failed to follow up on a gradual does reduction (GDR) for psychotropic medications for 2 (Resident 6 and 27) and failed to obtain the rational for the continued use of an as needed (PRN) medication that exceeded 14 days for 2 (Resident 17 and 27) of 5 sampled residents. The facility staff identified a census of 31. The Findings Are: A. A record review of facility policy Antipsychotic Use Policy and Procedure with revision date of November 2022, revealed a policy statement To ensure neuroleptics, hypnotics, sedative, antidepressant, anxiolytic, and antipsychotic medications will be used only when it is necessary to treat a specific condition. The policy also revealed that PRN (as needed) orders for anti-psychotic drugs were to be limited to 14 days and could not be renewed unless the attending physician or prescribing practitioner evaluated the resident for the appropriateness of that medication. B. A record review of Resident 27's Minimum Data Set (MDS), a federally mandated comprehensive assessment tool used for care planning, dated 7/16/24 revealed that Resident 27 had a Patient Health Questionnaire (PHQ-9), a validated interview that screens for symptoms of depression and provides a standardized severity score and a rating for evidence of a depressive disorder, score of 0/27 which indicated the resident did not have depression, and had diagnoses of parkinsonism, depression, and hallucinations. The MDS also revealed that the resident had been taking antipsychotic, antianxiety, and antidepressant medications and that the physician had not attempted a GDR of their medications. A record review of Resident 27's physician's orders printed on 9-03-2024 revealed the following orders: -Prozac (an antidepressant medication) 40 milligrams (MG) one time a day related to depression. This order had a start date of 5/13/24 and did not have an end date or duration indicated. -Lorazepam (an anxiolytic or anti-anxiety medication) 0.5 MG, give 1 tablet by mouth every 30 minutes as needed for anxiety and give 2 tablets by mouth every 30 minutes as needed for anxiety or shortness of breath. This order had a start date of 6/3/24 and did not have an end date or duration indicated. -Quetiapine Fumarate (Seroquel, an antipsychotic medication) 25 MG tablet, give 12.5 MG every 12 hours as needed for health maintenance related to adjustment disorder with depressed mood. The order also stated to give 12.5 MG at bedtime for health maintenance related to adjustment disorder with depressed mood. This order had a start date of 2/21/24 and did not have an end date or duration indicated. A record review of Resident 27's medical records revealed the resident was seen by their primary provider that exceeded 14 days on the following dates: -2/22/24 -3/29/24 -4/24/24 -6/25/24 -8/20/24 A record review of Resident 27's medical records revealed no evidence of a GDR being attempted or rationale for not attempting a GDR for the resident's psychotropic medications, no evidence of a rationale for the continued use of the PRN psychotropic medication beyond 14 days, and no evidence of the resident being re-evaluated every 14 days for the continued use of their PRN antipsychotic medication. An interview on 9/3/24 at 8:55 AM with Nurse Consultant (NC)-A revealed the facility had no evidence of Resident 27's provider attempting a GDR of their psychotropic medications and confirmed there had been no provider visits besides the ones reflected in the resident's medical records. An interview on 9/3/2024 at 1:22 PM with the Advance Practice Registered Nurse (APRN) revealed the APRN saw Resident 27 approximately every 1-2 weeks for Hospice visits but that these visits were not conducted for the purpose of renewing Resident 27's PRN Seroquel prescription.

CONCERN (E)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0947 (Tag F0947)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

Licensure Reference 175 NAC 12-006.04(B)(ii)(1) Based on record reviews and an interview, the facility failed to ensure 12 hours of continuing education had been completed for 3 of 5 sampled employees. This had the potential to affect all residents who resided at the facility. The facility identified a census of 31. Findings are: A record review of the Facility Assessment with a last updated date of 5/19/2024 indicated continuing competence of nurse aides of at lest 12 hours per year is to be completed. A record review of a Course Completion History for Nurse Aide (NA) - K revealed a total of 3.85 training hours. A record review of a Course Completion History for Medication Aide (MA) - L revealed a total of 11.85 training hours. A record review of a Course Completion History for MA-M revealed a total of 9.1 training hours. A record review of a facility provided employee listing revealed NA-K was hired on 5/22/23, MA-L was hired on 9/9/22, and MA-M was hired on 9/1/22. An interview on 9/4/2024 at 9:55 An with the Administrator confirmed NA-K, MA-L, and MA-M had not met the required 12 hour of training per year.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

Licensure Reference Number 175 NAC 12-006.11(E) Based on observation, interview, and record review; the facility failed to ensure sanitary conditions in the kitchen and that food was used or discarded before their expiration dates to prevent the potential for foodborne illness. This had the potential to affect all 31 residents who ate from the kitchen. The Findings Are: A record review of facility policy Sanitation Inspection with copyright date of 2024 revealed all food service areas would be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies, and other insects. An initial kitchen tour conducted on 8/28/24 at 9:06 AM revealed the following observations: -The metal shelving unit where the metal pots and pans were stored had gray fuzzy matter along the shelves and sides of the unit as well as brown and black debris on the bottom of the unit, just below bottom shelf. -On a shelf above the handwashing sink there was a plastic bin that contained an unopened bottle of PF Chang's Teriyaki sauce with a best by date of 12/5/2023. -On a shelf next to the dishwashing sinks was a bag of biscuits that was dated 8/19. -The stovetop had a large amount of burned/cooked on food debris around all of the burners. -The dishwashing sink had an Ecolab 146 Multi-Quat Sanitizer dispenser which had a tube running from the dispenser into the sink. The end of the tube was resting inside a metal pot that was full of a yellowish liquid and food debris. -The window above the dishwashing sink was open and there was brown and gray debris on the interior windowsill. -There was a rolling cart next to the handwashing sink that had a tray on top of it with 4 Styrofoam bowls with cake slices in them and 5 plastic bowls with peach slices in them. None of the bowls were labeled or dated. -The floor throughout the kitchen had food debris and dried liquid splashes on it. Also, during the initial kitchen tour, the following items were observed in the walk-in refrigerator: -A plastic bag labeled diced onions that was dated 8/16. -A plastic tub labeled Tom Soup that was dated 8/14. -A plastic bag labeled turkey breast that was dated 8/14. -A plastic bag labeled chicken breast that was dated 8/19. -A plastic tub labeled marinara that was dated 8/20. -A plastic container labeled Chopped Garlic in Water with a best if used by date of 7/14/24. -A plastic container labeled parmesan cheese that was dated 5/25. A record review of the 2017 Nebraska Food Code revealed in section 3-501.17 that ready-to-eat, time/temperature-controlled foods should be clearly marked to indicate the date or day by which the food should be consumed or discarded, which is a maximum of 7 days. The date of preparation should be counted as day 1. An interview on 8/28/24 at 9:27 AM with the Dietary Manager (DM) revealed that food items were to be used or disposed of within 5 days of opening or preparing and that the bowls of cake and peaches on the rolling cart were not labeled and had been left out from the evening prior. The DM confirmed each of the outdated items identified during the initial kitchen tour. The DM also confirmed the gray fuzzy matter and debris on the shelves, stovetop, and windowsill should have been cleaned and that the Ecolab tube should not have been resting in the pot full of liquid.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0925 (Tag F0925)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

Based on observation, interview, and record review; the facility failed to ensure there were no flying insects in the kitchen. This had the potential to affect all 31 residents who ate food prepared within the kitchen. The Findings Are: A record review of 2017 Nebraska Food Code, under section 6-501.111 revealed the premise shall be maintained free of insects. A record review of facility policy Pest Control Policy with revision date of March 2019 revealed that the environment would be monitored by facility staff and that there was to be an emphasis on the pest control program in the kitchen. A record review of facility policy Sanitation Inspection with copyright date of 2024 revealed that all food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies, and other insects. An observation on 9/3/24 at 9:54 AM in the kitchen revealed 4 insects flying around in the kitchen. The insects were observed landing on and walking on the steamtable, food prep counter, and other various surfaces in the kitchen. An observation on 9/3/24 at 12:02 PM revealed 3 insects flying around the steamtable, which contained foods that were to be served to the residents, and landing on the resident meal plates and steamtable countertop which Cook-N was using for cutting sandwiches in half. An interview on 9/3/24 at 1:00 PM with Cook-N confirmed there had been flying insects in the kitchen throughout that day. Cook-N stated the facility normally sprayed an industrial bug killer at night but that Cook-N wasn't sure it was being used each night and the flying insects had been worse over the previous couple of days.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0940 (Tag F0940)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

Licensure Reference 175 NAC 12-006.04(B)(i) Based on record reviews and an interview, the facility failed to ensure five out of five sampled employees had completed initial orientation as required. This had the potential to affect all residents who resided at the facility. The facility identified a census of 31. Findings are: A record review of the Facility Assessment with a last updated date of 5/19/2024, under Section 3.4 Staff training/education and competencies, revealed training will be completed at orientation and refers to the orientation check list. A record review of Nurse Aide (NA) - G's personnel record provided by the facility revealed no evidence initial orientation had been completed. A record review of Licensed Practical Nurse (LPN) - H's personnel record provided by the facility revealed no evidence initial orientation had been completed. A record review of NA-I's personnel record provided by the facility revealed no evidence initial orientation had been completed. A record review of Registered Nurse (RN) - B's personnel record provided by the facility revealed no evidence initial orientation had been completed. A record review of NA-J's personnel record provided by the facility revealed no evidence initial orientation had been completed. An interview on 9/4/2024 at 11:30 AM with the Administrator revealed the facility did not have evidence initial orientation had been completed for NA-G, LPN-H, NA-I, RN-B, or NA-J.

Apr 2024 2 deficiencies

CONCERN (D) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Licensure Reference 175 NAC 12-006.09D7(3) Based on interviews and record reviews, the facility failed to implement interventions to reduce falls for 1 (Resident 1) of 3 sampled residents. The facility identified a census of 34. The findings are: A record review of the facilities' policy Fall Prevention and Response Policy with a last revised date of October 2022 revealed post-fall documentation includes root-cause analysis, interventions, response to interventions, and effectiveness of interventions. It also revealed the Interdisciplinary Team Fall Committee will meet and complete a fall review on each resident the following week where the care plan will be updated with a new or decided interventions. A record review of an admission Record indicated the facility admitted Resident 1 on 8/19/2021 with diagnoses of: epilepsy, vascular dementia, depression, anxiety, and osteoarthritis. The quarterly Minimum Data Set (MDS), with an Assessment Reference Date of 1/23/2024 revealed Resident 1 was severely impaired with daily decision-making skills. Resident 1 required moderate assistance with all Activities of Daily Living. Resident 1 also had a history of more than two minor injury falls and more than two non-injury falls since admission. A record review of the facility provided incident reports revealed Resident 1 had fallen on 1/11/2024. Resident 1 was found on the floor of the resident's room in front of the television. A record review of Resident 1's undated Care Plan revealed no new intervention was placed after the fall on 1/11/2024. An interview on 4/2/2024 at 9:56 AM with Registered Nurse (RN)-A confirmed the facility does not utilize paper Care Plans and all interventions are updated right away after a fall occurs on the electronic Care Plan. An interview on 4/2/2024 at 10:49 AM with RN-A confirmed no new interventions were placed after Resident 1's fall on 1/11/2024. RN-A had shaken head in a no gesture and had stated What else are you going to do? We just continue to use the same interventions. An interview on 4/2/2024 at 10:55 AM with the Social Services Director (SSD) confirmed no new intervention was put in place after Resident 1's fall on 1/11/2024, and had stated I'm not finding it, it should have been put on the Care Plan.

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Report Alleged Abuse (Tag F0609)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.02(8) Based on record review and interview, the facility failed to submit their investigation of a fall with major injury to the state agency within five working days for 3 (Residents 1, 2, and 3) of 4 sampled residents. The facility census was 34. The Findings Are: A record review of the facility policy, Abuse Prevention Policy and Procedure dated December 2022, revealed in the investigation section that the facility will investigate all incidences such as falls, bruises, medication errors, resident complaints, etc. The Reporting and Response section revealed that the Administrator, DNS, or Nursing Supervisor will make sure that a report is filed, that the internal investigation begins immediately, and the appropriate reporting takes place. A record review of a document provided by the facility Administrator revealed the facility attempted to fax a 5-page Investigation Report to (402) [PHONE NUMBER] on 3/6/24 at 5:47 PM. The document stated pages not sent due to No Answer. The 5-page document included details regarding Resident 1's fall on 3/2/24, that the resident's arm had been broken, follow up care provided, and an intervention of assess resident's clothing for ease of toileting. The section regarding when the next re-evaluation would take place states, When resident can have his cast off, we can assess more thoroughly. There was no evidence that the facility had re-attempted to send the document to the state agency. A record review of a document provided by the facility administrator revealed Resident 2 had a fall on 12/19/23, the facility had called APS on 12/20/23, and that the facility had filled out the document on 12/23/23. The document included details regarding the resident's fall, that the resident's hip had been broken, follow up care provided, and an intervention of Increase rounds and encourage resident to come out to the living room where (gender) can interact with more people. The section regarding when the next re-evaluation would take place states, We will be monitoring (gender) when (gender) returns from Scottsbluff. There was no evidence that the facility had attempted to send this report to the state agency. A record review of a document provided by the facility Administrator revealed Resident 3 had a fall on 12/21/23 and the Investigative Report was filled out on 12/22/23. The document included details regarding the resident's fall, that the Resident 3's arm had been broken, follow up care provided, and an intervention of increase rounding and encourage resident to come out to the dining room. The section regarding when the next re-evaluation would take place states We are monitoring (gender) to see if this is something that will work. (Gender) is a very interdependent (gender). There was no evidence that the facility had attempted to send this report to the state agency. An interview on 4/2/24 at 10:48 AM with the Administrator confirmed that the (gender) was the person who was responsible for sending investigations to the state agency. The administrator also confirmed that the fax sheet for Resident 1 was sent to the fax number listed, that Resident 1, Resident 2, and Resident 3's investigations were submitted on an outdated version of the investigation template that contained an incorrect fax number for the state agency, and that the (gender) had been sending investigations to that fax number.

Aug 2023 1 deficiency

CONCERN (E) 📢 Someone Reported This

A family member, employee, or ombudsman was alarmed enough to file a formal complaint

Potential for Harm - no one hurt, but risky conditions existed

Deficiency F0940 (Tag F0940)

Could have caused harm · This affected multiple residents

Read full inspector narrative →

License Reference Number 175 NAC 12-006.04B Based on interviews and record review, the facility failed to provide education/orientation/in-services specific to elopement. The failure had the potential to affect all facility residents identifies as at risk for elopement. The facility identified a census of 33 residents at the time of the survey. Findings are: A record review of the facility's Incident Reports revealed there had been resident elopements on 10/20/2022, 3/18/2023, 7/27/2023, and 8/3/2023. A record review of the facility's training schedule and courses for the year 2023 revealed Abuse, Neglect, and Exploitation were not included in the training schedule. In an interview on 8/15/23 at 9:30 AM with the Interim Administrator (IA)-A revealed they were not sure elopement staff education had occurred before or after residents had eloped from the facility due to changes in management. An interview on 8/15/23 at 11:38 AM with Maintenance (M)-revealed they did not receive education on elopements. An interview on 8/15/2023 at 10:00 AM with Nursing Assistant (NA)-C revealed the facility has assigned Relias training. NA-C confirmed they did not complete the training. An interview on 8/15/2023 at 12:15 PM with the Assistant Director of Nursing (ADON) was unable to access completion of training for four of four requested staff members (NA/MA-D, NA-F, NA-G, and NA-H). ADON revealed the previous administrator and previous directors of nursing (DON) did have access to review Relias training. ADON was unsure of who was responsible for tracking staff training/staff education for completion. An interview on 8/15/20203 at 12:20 PM with Interim Administrator (IA-A) revealed the expectation was for staff to complete monthly assigned Relias training. IA-A confirmed staff training should be followed up by the facility Administrator to ensure completion, but it had not been getting done. IA-A had revealed they were aware there were issues, and their process was broken. IA-A further revealed there had not been any all-staff meetings, so there had not been good communication. An Interview on 8/16/2023 at 12:20 PM, with IA-A confirmed they could not provide documentation that all facility staff, including NA-F, NA-G, NA-H, and NA/MA-D had completed the required Relias training or in-services which included elopement. An Interview on 8/16/2023 at 12:20 PM with the Interim Director of Nursing (DON), confirmed they could not provide documentation that all facility staff including NA/MA-D, NA-F, NA-G, and NA-H had completed the required annual Relias training, which included elopement. An interview on 8/16/23 at 2:40 PM with IA-A revealed they could have looked up staff training, but they were sure training was not 100% completed for all facility staff. IA-A confirmed the Administrator was ultimately responsible to ensure training had been completed. IA-A also revealed there had not been any in-service trainings in almost a year; since the October 2022 elopement incident. IA-A confirmed they could not provide staff competencies for NA/MA-D, NA-F, NA-G, and NA-H.

Jul 2023 2 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Accident Prevention (Tag F0689)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7a Based on observation, record review, and interview, the facility failed to ensure staff observed residents take their medication to prevent accidents. This affected 1 (Resident #26) of 1 resident observed to have been given medication by a staff member who did not observe the resident take the medication before leaving the room. Findings included: A review of the facility's Medication Administration and Ordering Policy, dated 2019, revealed the policy did not address medications being left with a resident to administer without supervision of staff. A review of the admission Record for Resident #26 revealed the facility admitted the resident on 05/31/2023 with diagnoses that included type 2 diabetes mellitus, major depressive disorder, and cerebral infarction. A review of the admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 06/07/2023, revealed Resident #26 had a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The resident required extensive assistance from staff with most activities of daily living (ADLs). The Care Plan, with a last reviewed date of 06/09/2023, revealed focus areas indicating Resident #26 had an ADL self-performance deficit and impaired cognitive function/impaired thought processes related to a recent cerebral vascular accident. Upon entering Resident #26's room on 07/24/2023 at 10:13 AM, the surveyor observed the resident holding a medication cup with six pills in it. The resident stated Certified Medication Aide (CMA) A had given them the cup of medications and walked out. The resident stated CMA A always gave them the medication cup with medication in it and walked out of the room. Resident #26 stated CMA A was the only staff member who did not wait for them to take their medications before they left the room. During an interview on 07/25/2023 at 10:50 AM, CMA A stated they were supposed to observe a resident taking their medications and not leave the medication for the resident to take without supervision. During an interview on 07/25/2023 at 11:09 AM, the Director of Nursing (DON) stated a resident should be observed by staff while the resident took their medication. The DON stated negative outcomes that could occur when a resident was not observed taking their medication included the resident could choke, the resident might not take all of their medication, and/or another resident could take the medication. The DON stated they expected a CMA or licensed staff to observe a resident take their medication before they left the room. During an interview on 07/25/2023 at 11:13 AM, the Administrator stated staff should observe a resident taking their medications prior to leaving the room.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

LICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observations, interviews, and facility policy and document review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety and to prevent foodborne illness. Specifically, the facility failed to keep the food items on the steam table at temperatures of 135 degrees Fahrenheit (F) or above, failed to ensure residents were not served food items from the steam table that were lower than 135 degrees F, failed to ensure food temperatures were recorded and food temperature logs were kept, and failed to date and label opened food items. This had the potential to affect all residents that received food items from the kitchen. Findings included: 1. Review of the facility's policy titled, Food: Preparation, revised 9/2017, revealed, 13. All foods will be held at appropriate temperatures, greater than 135 [degrees] F (or as state regulation requires) for hot holding, and less than 41 [degrees] F for cold food holding. 14. Temperature for TCS [time/temperature control for safety] foods will be recorded at time of service, and monitored periodically during meal service periods. During an observation of the lunch meal in the kitchen on 07/26/2023 at 11:55 AM, Dietary Aide/Cook (DA) F, took the temperatures of the food on the steam table. The food on the steam table including sliced ham, pureed ham, chicken breast, mechanical soft chicken breast, pureed cabbage, gravy, and pureed bread. The temperatures were as follows: - sliced ham: greater than 130 degrees F; - chicken breast: 120 degrees F; - pureed ham: 120 degrees F; and - pureed bread: 110 degrees F. At 12:09 PM, DA F took the temperatures of the following food items: - chicken breast: 130 degrees F; - pureed ham: 120 degrees F; and - pureed bread: 118 degrees F. At 12:44 PM, DA F took the temperature of the sliced ham and the temperature was 120 degrees F. The gravy temperature was 114 degrees F and the mechanical soft chicken breast temperature was 100 degrees F. On 07/26/2023 at 1:16 PM, it was determined that seven residents were served the food items from the steam table that were below 135 degrees F. Following the observation, all food temperature logs were requested from the Area Dietary Manager (DM). Review of the facility's food temperature log titled, Service Line Checklist, dated 07/26 (no year), revealed that food temperatures were taken and recorded during Lunch for four food items which included: sliced ham (140 degrees F), pureed ham (130 degrees F), mashed potatoes (170 degrees F) and cabbage (180 degrees F). The food log for 07/26/2023 was the only log provided by the DM; the DM could not find any other logs. During an interview on 07/26/2023 at 2:15 PM, DA F said they started three to four weeks ago and had some prior knowledge of food safety before starting at the facility. DA F stated that a dietary aide trained them on temperatures and said that foods should be cooked to a temperature of at least 165 degrees F and recorded every day. DA F stated that food holding temperatures should be between 140 degrees F and 175 degrees F and re-heated if the food was not at the proper temperature. DA F stated that all temperatures must be recorded. The DA revealed that a few food temperatures during the noon meal did not meet the temperature standards and caused them to re-heat and re-take the temperatures of those foods. DA F contributed the low temperatures to rushing to get lunch served to the residents during the kitchen survey process. DA F said that they took temperatures on all foods but forgot to record them. During an interview on 07/26/2023 at 2:04 PM, the DM stated the facility's dietary staff were probably not trained because they did not know proper food temperatures. The DM said that new staff members received one-on-one training with the dietary food manager on topics such as holding temperatures, dating, labeling, cleaning, and every aspect of the kitchen. The DM indicated that each employee had an educational checklist form that was completed and placed in the employee's personnel file. The DM stated that they planned to locate and review the training checklists for the cook and other kitchen staff. The DM said that hot foods should be cooked to a temperature of 165 degrees F and held at a temperature of 135 degrees F. The DM added that the cook was responsible for taking and recording temperatures of all food served. During an interview on 07/26/2023 at 1:46 PM, the Director of Nursing (DON), stated it was expected that kitchen staff had knowledge of food temperature requirements. The DON indicated the food for the lunch meal had temperatures that were too low and indicated the residents were being monitored. The DON stated that food temperature logs should be kept. During an interview on 07/26/2023 at 2:26 PM, the Administrator stated that it was expected that the temperatures of foods be taken and recorded in a food temperature log according to regulatory requirements. The Administrator stated that the Dietary Manager was expected to train their employees, including contractors, and that the contracting company knew they were expected to record food temperatures. The Administrator added that if the kitchen staff could not find the temperature logs, that meant they did not exist. 2. Review of the facility's policy titled, Food Storage: Dry Goods, revised 9/2017, revealed, 5. All packaged and canned food items will be kept clean, dry, and properly sealed. 6. Storage areas will be neat, arranged for easy identification, and date marked as appropriate. Review of an undated facility document titled, Kitchen Notes revealed a Labeling and Dating section that indicated All food items including leftover out of original packing [sic] must have Name of Food and two dates - Date of Prep/Open, Used by Date. A concurrent observation and interview was completed on 07/25/2023 starting at 7:48 AM with the Area Dietary Manager (DM). The following was observed: - Devil's food cake mix, cornbread mix, powdered sugar, and pancake mix were all partially opened and undated. - An opened brown gravy mix with a date of 06/16/2023. The mix did not have a discard/use-by date and it was not enclosed in a sealed container. - Four unidentified opened, unlabeled, and undated syrup bottles. - An opened (almost empty) gallon of vegetable oil and a 64-ounce (oz) oatmeal container that was undated and unlabeled. - The bulk flour bin had an opened date of 08/14/2022 but did not have a discard date. - The breadcrumbs bin was not dated and was unlabeled. The DM verified the devil's food cake mix was missing the opened date and discard date. The DM stated all opened food items should include the initials of the person that opened the food item, the opened date, and the discard date. The DM added that the cook opened the oatmeal that morning, but it still required an opened date, discard date, and initials of the person that opened it. During an interview on 07/26/2023 at 8:08 AM, Dietary Aide (DA) G stated that food items must be dated with the open date. DA G added if the discard or expiration date was not known then DA G would determine the usability of the product by looks and smell. During an interview on 07/26/2023 at 2:26 PM, the Administrator stated it was their expectation that kitchen food products were labeled, dated when opened, and dated with an expiration or discard date.

May 2022 4 deficiencies

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Resident Rights (Tag F0550)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Licensure Reference Number: 175 NAC 12-006.05 (21) Based on observations and interviews; the facility failed to ensure that staff were seated to assist one current sampled resident (Resident 18) with eating to promote dignity. The facility census was 31 with 12 current sample residents. Findings are: Observations on 5/12/22 at 9:15 AM revealed Resident 18 seated in the dining room for breakfast. Further observations revealed LPN (Licensed Practical Nurse) - A standing next to the resident and feeding the resident a bowl of cereal. Interview with the Director of Nursing on 5/16/22 at 3:05 PM revealed that the resident was dependent on staff for cueing and eating. Further interview confirmed that staff were to sit next to the resident while assisting them to eat to promote dignity.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

ADL Care (Tag F0677)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Licensure Reference Number: 175 NAC 12-006.09D1c Based on observations, record review and interview; the facility failed to ensure that staff assisted one current sampled resident (Resident 18), dependent on staff, with a meal when it was served. The facility census as 31 with 12 current sampled residents. Findings are: Observations of the dining room on 5/12/22 at 12:20 PM revealed staff served a meal for Resident 18. Observations at 1:00 PM revealed the resident had not eaten any of the food. Further observations at 1:05 PM revealed Care Assistant - B sat down next to the resident to assist with the meal. Observations at 1:30 PM revealed that the resident had left the dining room and had eaten a few bites of food. Review of the Care Plan, goal date 7/19/22, revealed that the resident was at risk for further weight loss and required cueing and assistance with eating. Interview with the Director of Nursing on 5/16/22 at 3:05 PM confirmed that the resident required encouragement and assistance with meals. Further interview confirmed that staff should assist the resident to eat when the meal is served to ensure proper food temperatures and palatability.

CONCERN (D)

Potential for Harm - no one hurt, but risky conditions existed

Quality of Care (Tag F0684)

Could have caused harm · This affected 1 resident

Read full inspector narrative →

Licensure Reference Number: 175 NAC 12-006.09D Based on record review and interview, the facility failed to ensure that a follow up assessment was completed after obtaining a low blood pressure reading for one current sampled resident (Resident 27). The facility census was 31 with 12 current sampled residents. Findings are: Review of Resident 27's MAR (Medication Administration Record), dated May 2022, revealed that the resident received routine medication for high blood pressure including Lisinopril. Further review revealed that on 5/11/22 the resident's blood pressure was 78/63. Review of the Care Plan, goal date 7/20/22, revealed that the resident had a diagnosis of Hypertension (high blood pressure). Review of the medical record, including the Vital Signs and Progress Notes revealed no documentation of an assessment of the resident's condition with a low blood pressure reading or follow up blood pressure readings. Interview with the DON (Director of Nursing) on 5/12/22 at 2:10 PM confirmed that the blood pressure reading was abnormally low for the resident. Further interview confirmed that there was no follow up assessment or blood pressure readings in the medical record. The DON confirmed that the nurses should have completed and documented an assessment of the resident including follow up blood pressure readings until it was stable.

CONCERN (F)

Potential for Harm - no one hurt, but risky conditions existed

Food Safety (Tag F0812)

Could have caused harm · This affected most or all residents

Read full inspector narrative →

Licensure Reference Number: 175 NAC 12-006.11E Based on observations and interview, the facility failed to ensure that 1) uncovered glasses of water were not placed on the dining room tables before residents arrived and 2) ice was not build up around the freezer door to reduce the risk of cross contamination. The facility census was 31 with the potential to affect all of the residents. Findings are: A. Observations of the dining room on 5/11/22 at 11:50 AM and on 5/12/22 at 11:45 AM revealed uncovered glasses of water on the dining room tables before the residents arrived in the dining room. B. Observations of the walk in freezer, during the initial tour of the kitchen on 5/11/22 at 10:15 AM and on 5/16/22 at 11:15 AM revealed a build up of ice, approximately three inches wide, around the freezer door. Interview with the District Dietary Manager on 5/16/22 at 11:15 AM confirmed that the uncovered glasses of water should not be placed on the dining room tables before the residents arrive in the dining room to reduce the risk for cross contamination. Further interview confirmed that the freezer door needed to be repaired to eliminate the ice build up around the door to reduce the risk of cross contamination. The District Dietary Manager confirmed that these issues had the potential to affect all of the residents. Reference: Review of the 7/21/2016 version of the Food Code, based on the United States Food and Drug Administration Food Code and used as an authoritative reference for food service sanitation practices, revealed the following: 4-501.11 (A) Equipment shall be maintained in a state of repair and condition that meets the requirements specified under Parts 4-1 and 4-2. (B) Equipment components such as doors, seals, hinges, fasteners and kick plates shall be kept intact, tight, and adjusted in accordance with manufacturer's specifications. 3-307.11 Food shall be protected from contamination that may result from a factor or source not specified under Subparts 3-301 - 3.306.

Understanding Severity Codes (click to expand)

Life-Threatening (Immediate Jeopardy)

J - Isolated K - Pattern L - Widespread

Actual Harm

G - Isolated H - Pattern I - Widespread

Potential for Harm

D - Isolated E - Pattern F - Widespread

No Harm (Minor)

A - Isolated B - Pattern C - Widespread

Questions to Ask on Your Visit

"Why is there high staff turnover? How do you retain staff?"
"Can I speak with families of current residents?"
"What's your RN coverage like on weekends and overnight?"

Our Honest Assessment

Strengths

• No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
• No fines on record. Clean compliance history, better than most Nebraska facilities.

Concerns

• 27 deficiencies on record. Higher than average. Multiple issues found across inspections.
• Grade F (35/100). Below average facility with significant concerns.
• 63% turnover. Above average. Higher turnover means staff may not know residents' routines.

Bottom line: Trust Score of 35/100 indicates significant concerns. Thoroughly evaluate alternatives.

Email me this report

About This Facility

What is Crest View Care Center's CMS Rating?

CMS assigns Crest View Care Center an overall rating of 1 out of 5 stars, which is considered much below average nationally. Within Nebraska, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.

How is Crest View Care Center Staffed?

CMS rates Crest View Care Center's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 63%, which is 17 percentage points above the Nebraska average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 73%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.

What Have Inspectors Found at Crest View Care Center?

State health inspectors documented 27 deficiencies at Crest View Care Center during 2022 to 2025. These included: 27 with potential for harm.

Who Owns and Operates Crest View Care Center?

Crest View Care Center is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by LANTIS ENTERPRISES, a chain that manages multiple nursing homes. With 70 certified beds and approximately 30 residents (about 43% occupancy), it is a smaller facility located in Chadron, Nebraska.

How Does Crest View Care Center Compare to Other Nebraska Nursing Homes?

Compared to the 100 nursing homes in Nebraska, Crest View Care Center's overall rating (1 stars) is below the state average of 2.9, staff turnover (63%) is significantly higher than the state average of 46%, and health inspection rating (1 stars) is much below the national benchmark.

What Should Families Ask When Visiting Crest View Care Center?

Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's high staff turnover rate and the below-average staffing rating.

Is Crest View Care Center Safe?

Based on CMS inspection data, Crest View Care Center has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Nebraska. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.

Do Nurses at Crest View Care Center Stick Around?

Staff turnover at Crest View Care Center is high. At 63%, the facility is 17 percentage points above the Nebraska average of 46%. Registered Nurse turnover is particularly concerning at 73%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?

Was Crest View Care Center Ever Fined?

Crest View Care Center has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.

Is Crest View Care Center on Any Federal Watch List?

Crest View Care Center is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.

Facility Details

Beds: 70
Avg. Residents: 30
Occupancy: 43.9%
Ownership: For profit - Limited Liability company
Chain: LANTIS ENTERPRISES
Medicare: Yes
Medicaid: Yes
Sprinklers: Yes

Trust Score Breakdown

Base Score: 50
1-Star Rating: +0
High Turnover: -5
27 Deficiencies: -10
Final Score: 35/100

Nearby Alternatives

Ponderosa Villa 1-star

View all in Chadron →

Check Bed Availability

Data: CMS Medicare Care Compare

Updated: November 2025

Facility ID: 285150