Hillcrest Firethorn
For profit - Corporation
72 Beds
Independent
Data: November 2025
Trust Grade
65/100
#87 of 177 in NE
Photo by Hillcrest Firethorn
Photo by Hillcrest Firethorn
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1 / 5 photos
Last Inspection: April 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Hillcrest Firethorn has a Trust Grade of C+, indicating that it is slightly above average but not exceptional. In Nebraska, it ranks #87 out of 177 facilities, placing it in the top half, while in Lancaster County, it is #9 out of 14, meaning only one local option is better. The facility's trend is worsening, with the number of issues increasing from 4 in 2024 to 6 in 2025. Staffing is a notable strength, rated 4 out of 5 stars with a turnover rate of 39%, which is below the state average, indicating that employees tend to stay and build relationships with residents. However, there are concerning incidents, such as failure to provide a resident with the appropriate bowel management program, leading to discomfort, and multiple food safety violations that could risk foodborne illness for residents. Overall, while there are strengths in staffing, the increasing number of health and safety issues raises significant concerns.
- Trust Score
- C+
- In Nebraska
- #87/177
- Safety Record
- Moderate
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 39% turnover. Near Nebraska's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Nebraska facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 29 minutes of Registered Nurse (RN) attention daily — below average for Nebraska. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 12 deficiencies on record. Higher than average. Multiple issues found across inspections.
65/100
Top 49%
Needs review
4 → 6 violations
★★★☆☆
3.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★★
5.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 4 issues
2025: 6 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (39%)
9 points below Nebraska average of 48%
Facility shows strength in staffing levels, quality measures, fire safety.
The Bad
3-Star Overall Rating
Near Nebraska average (2.9)
Meets federal standards, typical of most facilities
Staff Turnover: 39%
Near Nebraska avg (46%)
Typical for the industry
The Ugly 12 deficiencies on record
1 actual harm
Apr 2025
4 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.10(A)(i)
Based on observations and interviews, the facility failed to assess the resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.10(A)(i)
Based on observations and interviews, the facility failed to assess the resident for safe self-administration (something is done or given by oneself, rather than by someone else, particularly in the context of medications or tests) of medications and obtain orders for bedside medication for 2 Residents (Resident 2 and 40) out of 6 sampled residents. The facility census was 56.
Findings are:
A record review of the facility policy Hillcrest Firethorn Medication Management Policy dated 1/1/23 revealed in the policy explanation and compliance guidelines:
-Patients may self-administer medications if they are deemed competent to do so by the nursing team. A self-administer assessment should be completed to determine competency.
Hillcrest Health Services Self-Administration of medication with no date policy: The Director of Clinical Services or designee will assess the ability to self-administer medications of residents requesting to self-administer.
-The Director of Clinical Services or qualified designee will complete an assessment of competency.
-An order will be obtained that resident can self-administer medications, stating that he resident is capable of self-medicating.
-The nursing team members will observe resident for changes in behaviors or condition during their daily interactions with the resident.
A.
A record review of the admission record with a printed date of 3/27/25 revealed Resident 2 was admitted to the facility on [DATE] with the diagnosis of fracture (broken bone) of right lower leg, depression (a common mental health condition characterized by persistent feelings of sadness, hopelessness, and loss of interest in activities previously enjoyed), anxiety (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), hypertension (a condition in which the force of blood against the walls of the arteries is consistently too high) and edema (a medical condition characterized by the excessive accumulation of fluid in the body's tissues).
A record review of the Minimum Data Set (MDS, a comprehensive assessment of each resident's functional capabilities) dated 3/7/25 revealed a BIMS (Brief Interview for Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 15, which indicated the resident was cognitively intact.
A record review of Resident 2's physician's orders with a printed dated of 3/27/25 revealed orders for:
-Breztri Aerosphere Inhalation (a prescription inhaler used to treat COPD, 2 puff inhale orally two times a day,
-Fluticasone Propionate Nasal Suspension (corticosteroid medication used to treat inflammatory conditions such as allergic rhinitis (hay fever), nasal polyps, and asthma), 2 spray in each nostril one time a day,
-lubricating Plus Eye Drops (provide moisture and relief for dry eyes due to temporary causes, like being tired or being in a dry climate) 0.5 % Instill 1 drop in both eyes every 6 hours as needed.
A record review of Resident 2's medical records revealed no evidence of a self-administration assessment being done or a doctor's orders to self-administer medications.
An observation on 03/31/25 at 9:45 AM revealed Resident 2 sitting in a recliner with a medicine cup full of pills, an inhaler, eye drops, a nebulizer treatment (using a device to convert liquid medication into a fine mist (aerosol) that can be inhaled, delivering the medication directly to the lungs and respiratory system for conditions like asthma or COPD (a common lung disease causing restricted airflow and breathing problems) full of medicine, and a bottle of nasal spray sitting on tray table. Resident 2 stated (gender) does take (gender) medication after eating breakfast and will do the nebulizer treatment after taking (gender) pills. Resident 2 confirmed that (gender) had already done the nasal spray.
An observation on 04/01/25 at 10:01 AM with Resident 2 sitting in recliner with a medicine cup full of pills in the cup sitting on the tray table with a glass of water, an inhaler, eye drops on side compartment of tray table and a bottle of nasal spray.
An interview on 4/1/25 at 11:00 AM with Clinical Care Coordinator (CCC)-A confirmed that Resident 2 did not have an order for self-administration of medications and an assessment for safe self-administration of medications for Resident 2 had not been done and it should have been done.
B.
A record review of the admission Record with the printed date of 3/27/25 revealed Resident 40 was admitted to the facility on [DATE] with the diagnosis of pheumothorax (a medical condition where air enters the pleural space, the area between the lung and chest wall), Bronchiectasis (a chronic lung condition characterized by the permanent widening and thickening of the airways (bronchi) in the lungs), Respiratory failure (a condition where the lungs are unable to adequately perform their primary function of gas exchange, leading to either dangerously low oxygen levels (hypoxemia) or dangerously high carbon dioxide levels (hypercapnia) in the blood), and anxiety disorder (A mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities).
A record review of the MDS dated [DATE] revealed a BIMS score of 12 indicating Resident 40 had moderate cognitive impairement.
Record review of Resident 40's physician's orders with a printed date of 3/27/25 revealed orders for: -Ipratropium-Albuterol Inhalation Solution 0.5-2.5 ml (Ipratropium-Albuterol), 1 vial inhale orally via nebulizer four times a day.
A record review of Resident 40's medical records revealed no evidence of a self-administration assessment for medication being done or of a doctor's order for Resident 40 to self-administer medication.
An observation on 3/26/25 at 12:54 PM revealed Resident 40 sitting in recliner with a nebulizer treatment (using a device to convert liquid medication into a fine mist (aerosol) that can be inhaled, delivering the medication directly to the lungs and respiratory system for conditions like asthma or COPD) sitting on the side table with liquid medicine in nebulizer cup. Resident 40 confirmed that (gender) will do the nebulizer treatment in a little while. Resident 40 confirmed that (gender) does the nebulizer treatments 4 times a day.
An observation on 3/27/25 at 12:30 PM revealed Resident 40 sitting in recliner with a nebulizer treatment sitting on the side table with liquid medicine in nebulizer cup.
An interview on 3/27/25 at 12:31 PM with Registered Nurse (RN)-B confirmed that (gender) is not aware of any residents on the long-term side having any orders for the residents to self-administrator medications.
An interview on 3/27/25 at 1:00PM with CCC-A confirmed that there was medicine in the medication cup of the nebulizer treatment and that it should have not been left in the medication cup and not have the resident do the nebulizer treatment. CCC-A confirmed that there is no self-administration of medication with Resident 40 and Resident 40 does not have a physicians order to self -administered medications.
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 F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C.
A record review of Resident 112's admission Record revealed the resident was admitted on [DATE] with respiratory failure, he...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C.
A record review of Resident 112's admission Record revealed the resident was admitted on [DATE] with respiratory failure, heart failure, irregular heart rate, rectal cancer, high blood pressure, glaucoma (a condition in which increased pressure in the eye can lead to gradual loss of vision), and diabetes mellitus (a long-term condition in which the body has trouble controlling blood sugar and using it for energy).
A record review of Resident 112's admission MDS dated [DATE] revealed the resident had a Brief Interview for Mental Status score of 11, which indicated the resident had moderate cognitive impairment.
An observation made on 03/26/2025 at 1:50 PM revealed two bottles of latanoprost (eye drops used to treat glaucoma) solution and a tube of combination diphenhydramine (an antihistamine that blocks a chemical in your skin that cause redness, itching, and pain) and zinc (a substance that can soothe the skin and help with wound repair) cream in a plastic basin on the bathroom counter, and two bottles of miconazole (an anti-fungal medication) powder on the bathroom counter.
A record review of Resident 112's Order Summary Report dated 03/27/2025 revealed the following orders:
Latanoprost Solution 0.005 % Instill 1 drop in both eyes at bedtime for GLAUCOMA, and
Antifungal External Powder 2 % (Miconazole Nitrate (Topical)) Apply to abd [abdominal] folds topically every shift for Excoriation [redness and irritation]
The orders did not include directions for the resident to keep the medications at bedside or self-administer them, and there was no order for the diphenhydramine-zinc cream.
An observation made on 03/27/2025 at 12:21 PM revealed two bottles of latanoprost solution and a tube of combination diphenhydramine and zinc cream in a plastic basin on the bathroom counter, and two bottles of miconazole powder on the bathroom counter.
An observation on 03/31/2025 at 8:00 AM revealed two bottles of latanoprost solution and a tube of combination diphenhydramine and zinc cream in a plastic basin on the bathroom counter, and two bottles of miconazole powder on the bathroom counter.
An interview on 03/31/2025 at 8:00 AM with the Clinical Care Coordinator (CCC) B confirmed there were two bottles of latanoprost eye drops, a tube of diphenhydramine-zinc cream, and two bottles of miconazole powder were unsecured in Resident 112's bathroom. CCC B confirmed that the resident was not capable of self-administration of medication, and the medications should not be unsecured in the resident's room.
Licensure Reference Number NAC 12-006.12(D)(i)
Based on observation, interview and record review; the facility failed to ensure that medications were stored in locked compartments for 3 (Residents 38, 30, and 112) of 6 residents sampled for medication administration. The facility census was 56.
Findings are:
Record review of facility provided policy dated 1/1/23 titled Medication Management revealed:
-patients may self administer medications if they are deemed competent to do so by the nursing team. A self administer assessment should be completed to determine competency.
-all medications that are requested to be available at bedside for patient self administration should be stored in a lockbox issued to the patient. The patient should be educated on the need for the medication safety and security and should be asked to notify the primary nurse of medications administered for documentation purposes.
Review of undated facility provided policy titled Self Administration of Medications revealed:
1. DCS or qualified designee will complete an assessment of competency
2. an order will be obtained that resident can self administer medications, stating that the resident is capable of self medicating
3. nursing team member will observe resident for changes in behavior or condition
4. residents who choose to self medicate must keep their medications secured, by keeping the medications in a locked container in their room
A.
Record review of Resident 38's Quarterly Minimum Data Set (MDS - a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) dated 1/27/25 revealed that the resident was admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 15, which indicated the residents cognition is intact.
Record review of Resident 38's physician order dated 7/1/2024 revealed an order for Systane complete ophthalmic solution and to instill one drop in left eye three times a day. Wait 5 minutes between drops.
During an observation on 03/31/25 at 7:37 AM revealed an unlabeled bottle of artificial tears were on Resident 38's on the nightstand in (gender) room. The resident self-administered several drops in each eye.
Record review of Resident 38's nursing assessments revealed no evidence of a self medication administration assessment being completed.
Record review of Resident 38's physician orders revealed no order to keep medication at bedside.
During an interview on 03/31/25 at 12:14 PM Registered Nurse (RN) - H corporate nurse consultant confirmed that Resident 38 did not have a self medication administration assessment completed and should have, it was further confirmed that the medication did not say may keep at bedside.
In an observation on 04/01/25 at 8:18 AM Resident 38 had artificial tears on (gender) nightstand.
In an interview on 04/01/25 at 8:18 AM Resident 38 Resident 38 stated (gender) used the eye drops when (gender) needs them.
B.
Record review of Resident 30's admission MDS dated [DATE] revealed resident was admitted to the facility on [DATE] with a BIMS score of 15.
Record review of Resident 30's physician orders dated 3/7/2025 revealed Deep Sea Nasal Spray solution 1 spray in each nostril four times a day, may keep at bedside and self administer.
Observation on 03/31/25 at 9: 38 AM revealed an undated bottle of deep nasal spray floor stock in Resident 30's room on the tray table.
During an interview on 3/31/25 at 9:39 AM Resident 30 stated (gender) uses it 4, 5, or 6 times everyday whenever (gender) needs it.
During an interview on 3/31/25 at 12:34 PM RN - H corporate nurse consultant confirmed that Resident 30's medication was not secured and should have been.
In an observation on 04/01/25 at 8:05 AM Resident 30's nasal spray on tray table in room.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 1-005.06(D)
Based on observation, interview, and record review the facility failed to impleme...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 1-005.06(D)
Based on observation, interview, and record review the facility failed to implement Enhanced Barrier Precautions (EBP- Specifically gowning and gloving to prevent the spread of bacteria resistant infection), for 4 (Resident 26, 17, and 34) of 7 sampled residents. The facility staff identified census of 56.
Finding are:
A record review of the facility Hand Hygiene Policy dated 03/01/2022 revealed:
A. Hand Hygiene Guidance
1. Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications:
- Immediately before touching a patient
- Before performing an aseptic (practice and procedure to prevent infection (e.g., placing an indwelling device) or handling invasive medical devices
- Before moving from work on a soiled body site to a clean body site on the same patient
- After touching a patient or the patient's immediate environment
- After contact with blood, body fluids, or contaminated surfaces
- Immediately after glove removal
2. Unless hands are visibly soiled, an alcohol-based hand rub is preferred over soap and water in most clinical situations due to evidence of better compliance compared to soap and water. Hand rubs are generally less
irritation to hands and, in the absence of a sink, are an effective method of cleaning hands.
B. Non-Surgical Hand Hygiene Technique
1. Handwashing with soap and water (either non-antimicrobial or antimicrobial)
- Wet hands with running water-avoid using hot water, to prevent drying of skin
- Apply hand washing agent to hand
- Vigorously rub hands together for at least 15-20 seconds, covering all surfaces
- Dry hands thoroughly with a disposable towel(s)
- Use disposable towel to turn of the water.
C. Gloves and Hand Hygiene
1. Gloves are not a substitute for hand hygiene prior to donning gloves, before touching the patient or the patient environment
2. Change gloves and perform hand hygiene during patient care,
a. Gloves have been damaged
b. Gloves have become visible soiled with blood or body fluids following a task
c. Moving from work on a soiled body site to a clean body site on the same patient or if another clinical indication for hand hygiene occurs
4. Never wear the same pair of gloves in the care of more than one patient
5. Carefully remove gloves to prevent hand contamination.
Record review of the facility Infection Prevention and Control Policy Effective date 03/01/2022 revealed:
Infection Control Program Requirements:
1. All team members will adhere to Standard Precautions to reduce the risk of exposure and prevent the transmission of infection of guests and personnel.
2. Gowns or aprons: Must be impervious and worn when there is a potential for blood or body fluid spatters or sprays. Examples may include venipunctures, catheter, or ca care of an
incontinent guest.
Record review of Resident 34's medical record revealed Resident 34 was admitted to the facility on [DATE] with a BIMS (Brief Interview of Mental Status 0 lowest to 15 highest) score of 6, suggesting severe cognitive impairment and a diagnosis of Neuromuscular Dysfunction of Bladder, unspecified (Loss of bladder control from nerve damage to bladder.)
Resident 34's plan of care revealed Resident 34 needed AM (morning) peri-care, (soap and water or wet wipes to clean the genital areas on male or female) suprapubic catheter care (Urinary tube to drain the bladder through the location in lower abdomen), and transfer to the recliner using an EZ-Stand Lift (Lift used to allow the resident to stand on lift and be moved by staff).
An observation on 3/31/2025 at 8:40 AM revealed Nurse Tech NT-C and NT-D (Nursing Technician) entered Resident 34's room to perform peri-cares, suprapubic catheter care and to transfer resident from the bed to the chair using an EZ Stand-Lift. NT-C and NT-D put on a gown and gloves to provide suprapubic catheter care to Resident 34 who was lying in bed. NT-C and NT-D proceeded to provide peri care using front to back wiping technique with wet wipes per facility policy and procedure. NT-D and NT-C then went into the bathroom to perform hand hygiene. NT-D washed hands for 12 seconds and then put on clean gloves and NT- C washed hands for 14 seconds and then put on clean gloves. NT-C and NT-D proceeded to get the Resident 34 dressed and used the EZ-Stand lift sling to transfer resident from the bed to the chair.
NT-D cleaned the EZ-Stand lift with sanitizer wipes but did not clean the EZ -Stand lift sling that was used on this Resident. The lift sling was placed on the EZ-Stand lift bar and pushed out of the room into the hallway. NT-C went into the bathroom and removed (gender) gloves and gown and washed hands with soap and water for 10 seconds before drying them with a paper towel. NT-D went into the bathroom and removed gloves and gown and (gender) washed hands with soap and water for 14 seconds before drying them with a paper towel.
An interview on 04/01/2025 at 09:10 AM with NT-D revealed that staff use the EZ-Stand lift and lift sling on all the Residents in the facility that need it.
A record review of the admission Record with the printed date of 9/9/24 revealed Resident 45 was admitted to the facility on [DATE] with the diagnosis of Unspecified Hydronephrosis (excessive fluid in a kidney,) Obstructive and Reflux Uropathy (Blockage in the urinary tract) Retention of urine, Disorientation (feeling lost, confused, or having a reduced sense of time, place, direction), Other Amnesia (loss of memory).
A Minimum Data Set (MDS-a comprehensive assessment of each resident's functional capabilities) dated 03/03/2025 revealed that Resident 45 had a BIMS (Brief Interview for Mental Status) of 10 for a scale of (00-15) suggesting moderate cognitive impairment and needed morning Foley catheter care (Cleaning the tube that is in the bladder and drains urine, typically into a bag).
A record review of admission Record revealed Resident 17 admitted with diagnosis of Obstructive Uropathy, Kidney Disease, Benign Prostatic Hyperplasia without lower urinary tract symptoms (Enlargement of prostate (Gland below the bladder in a male) that can cause urinary difficulty), and muscle weakness.
An observation of Resident 17 on 04/01/2025 at 10:37 AM revealed:
- Licensed Practical Nurse (LPN)-F washed hands for 35 seconds and put on gloves and gown and then put soap and hand towels on bedside table covered with towel.
- LPN-F put water in basin with washcloths and sat on bedside table and then LPN-F took off gloves and cleaned hands with sanitizer and put on clean gloves
- LPN-F put towel over Resident 17's lower abdomen just below (gender) supra pubic catheter site.
- LPN-F took off Slit Sponge with dried area size of a dime and colored light brown from catheter site.
- LPN-F used the same gloves put and put hands in clean water basin and took out a wash cloth and cleaned around suprapubic catheter site.
- LPN-F used the second wash cloth from basin and rinsed off catheter site and catheter tubing and dried area with clean towel.
- LPN-F changed gloves and sanitized hands and put on clean gloves.
- LPN-F opened 4x4 Slit Sponge dressing and applied it around the catheter tubing at opening on abdomen and then removed gloves and gown and performed hand hygiene.
Interview on 04/01/2025 at 11:06 AM with CCC-A revealed:
When providing catheter care and cleaning the skin for Resident 17's suprapubic catheter site the staff member should have changed gloves after handling the dirty Slit Site 4x4 dressing and put on clean gloves after hand hygiene was performed prior to putting hands into the clean basin of water to wash the catheter site.
A record review of the admission Record with the printed date of 3/31/25 revealed that Resident 26 was admitted to the facility on [DATE] with the diagnosis of Multiple Sclerosis (Chronic autoimmune disease that affects the central nervous system which includes the brain and spinal cord),Edema (swelling caused by fluid in your body's tissues), Neuromuscular Dysfunction of the bladder (damage to the nerves involved in the bladder control ,disrupts the communication between the brain and the bladder leading to various urinary problems), Hypertension ( a condition where the force of blood against the artery walls is consistently too high), Peripheral Vascular Disease (a condition that affects the blood vessels outside of the heart and brain),Colostomy (a Surgical procedure that creates and opening (stoma)in the abdominal wall to divert stool from the colon (large intestine) to an external bag), Urostomy (a surgical procedure that creates an opening (stoma) in the abdomen to divert urine from the kidneys directly to a collection bag on the outside of the body), Above the knee amputation of both right and left leg, Pressure Ulcer of /Sacral Region (a localized area of skin and underlying tissue damage that occurs over the bony prominence of the sacrum) Stage 3, and Depression(a common mental health condition characterized by persistent feelings of sadness, loss of interest, and low energy levels that can significantly impact daily life.
A record review of the MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities dated 1/13/25 revealed a BIMS (Brief Interview for Mental Status, a test to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score was 15 indicating the resident is cognitively intact.
An interview on 3/26/25 at 10 AM with Resident 26 confirmed that (gender) prefers to sleep in the power wheelchair.
An observation on 03/26/25 at 11:04 AM revealed that Resident 26 was sleeping in (gender) power wheelchair.
A record review of the Physicians orders with the printed date of 3/31/25 revealed orders for:
-Apply Calmoseptine to right ischial (buttock) area Twice a day and PRN (when needed), may cover with gauze to promote adherence.
-Colostomy Bag and Wafer, change two times a week and PRN
-Change Urostomy on Tuesday and Friday (bath days) and PRN
A record review of the Care Plan (written instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care) dated 8/19/24 indicated the need for Enhanced Barrier Precautions.
An observation on 03/27/25 at 9:25 AM with NT-D revealed (gender) washed hands for 20 seconds and applied gloves. NT-D then unhooked catheter tubing from catheter bag before transferring Resident 26 to lay down in bed for wound care treatment. NT-D did not put on a gown. CCC-A and NT-D did not have gowns on when transferring Resident 26 to lay down in bed for the wound treatment to (genders) buttocks. Both CCC-A and NT-D had rolled Resident 26 side to side. Resident 26 did not have on a brief or underwear. CCC-A confirmed that the gowns were locked up in the bottom drawer and did not know why the drawer was locked. CCC-A confirmed that there was an Enhanced Barrier Precaution sign taped to the closet door. Observation of RN-B performing hand hygiene and gathered supplies for the wound treatment. RN-B did apply gloves. RN-B did not put on the gown. RN-B did not wash the old cream off the buttocks of Resident 26, and (gender) applied the new cream. NT-D and CCC-A assisted Resident 26 back into wheelchair. NT-D then reattached the catheter tubing to the catheter bag. Both CCC-A and NT-D washed hands before leaving the room.
A record review of the sign attached to the closet door revealed Enhanced Barrier Precautions: Everyone must: Clean their hands, including before entering and when leaving the room. Providers and Staff must also wear gloves and a gown for the following High contact Resident Care Activities. Dressing, Bathing/showering, transferring, changing linens. Providing hygiene, changing briefs, or assisting with toileting. Device care or use: central lines, urinary catheter, feeding tube, tracheostomy, wound care: any skin opening requiring a dressing.
A record review of the Hillcrest Firethorn Enhanced Barriers Precautions Effective date 4/1/24 revealed Initiation of Enhanced Barrier Precautions:
A)
The facility will have the discretion in using EBP for residents who do not have a chronic wound oar indwelling medical device and are infected or colonized with an MDRO (Multidrug-Resistant Organism) that is
not currently targeted by CDC (Center for Disease Control).
B)
An order for Enhanced Barrier Precautions will be obtained for residents with any of the following, wounds (e.g., chronic venous stasis ulcers) and or indwelling medical devices (e.g central lines, urinary catheters,
tube feeding, tracheostomy/ventilator tubes) even if the resident is not known to be infected or colonized with a MDRO.
An interview on 3/27/25 at 10:00 AM with RN-B confirmed that (gender) did not wear a gown while performing the wound cares and should have put on a gown. RN-B confirmed that (gender) should of cleaned Resident 26 bottom before applying the new cream to Resident 26's bottom.
An interview on 3/27/25 at 10:00 AM with NT-D confirmed that (gender) should have put on a gown before performing cares for Resident 26.
An interview on 3/27/25 at 10:00 AM with the CCC-A confirmed that Resident 26 is in Enhanced Barrier Precautions. CCC-A confirmed that any staff member taking care of Resident 26 wounds, colostomy or urostomy should be in Enhanced Barrier Precautions. CCC-A confirmed that (gender), RN-B and NT-D should have been in Enhanced Barrier Precautions and was not in Enhanced Barrier Precautions. CCC-A confirmed that RN-B did not clean off the old barrier cream to Resident 26 bottom and should of been cleaned off before applying the new cream to Resident 26's bottom.
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
Licensure Reference Number 175 NAC 12-006.11(E)
Based on observations and interview the facility failed to label and date opened packages of food in the walk- in freezer and failed to cover items in t...
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Licensure Reference Number 175 NAC 12-006.11(E)
Based on observations and interview the facility failed to label and date opened packages of food in the walk- in freezer and failed to cover items in the walk in refrigerator and to discard processed food items passed the 7 day date to prevent the potential for food borne illness. This had the potential to affect all 56 residents. The facility census was 56.
Findings are:
An observation on 3/26/25 at 7:30 AM of the walk-in freezer revealed:
-An open box of beef patties not dated and open to air,
-An open box of chicken patties not dated and open to air,
-An open box of chicken fillets not dated and open to air,
-An open box of breakfast potatoes not dated and open to air.
An observation on 3/26/25 at 7:30 AM of the walk-in refrigerator revealed:
-A serving pan of soup with a ladle notch dated 3/16. No saran wrap over the serving pan or the area for the ladle notch to sit in.
-A serving pan of rice with no saran wrap or tin foil coving rice that appeared dried with a lid with a ladle notch dated 3/17.
An interview on 3/26/25 at 8:15 AM with the DM (Dietary Manager) confirmed that the items listed above were opened packages of food that should have been labeled, dated and sealed.
A record review of the facility policy Proper Food Storage dated 2/22/22 revealed:
-all food products must be covered
-clearly label all food with product or item name, preparation date, used by, expiration date or sell by date and prepared by.
-perishable foods discarded after 3 days.
A record review of the Nebraska Food Code dated 2017 revealed revealed that 81-2.282(2)(c ) Food shall be deemed to be adulterated (unsafe) if it has been manufactured, processes, packages, stored, or held under unsanitary conditions where it may have become unsafe for use as food and 3-501.14 and: P (i) Cooled to 1°C (34°F) within 48 hours of reaching 5°C (41°F) and held at that temperature until consumed or discarded within 30 days after the date of PACKAGING; P (ii) Held at 5°C (41°F) or less for no more than 7 days, at which time the food must be consumed or discarded.
Feb 2025
2 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Quality of Care
(Tag F0684)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 174 NAC 12-006.09(H)(iv)
Based on record review and observation, the facility failed to provide the f...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 174 NAC 12-006.09(H)(iv)
Based on record review and observation, the facility failed to provide the facility's outlined bowel management program for 1 (Resident 3) of 3 residents sampled and instead provided digital stimulation for Resident 3. The facility also failed to provide prompt medical attention for 1 (Resident 1) of 4 sampled residents. Facility census was 65.
Findings are:
A.
A record review of Resident 3's progress notes dated 2/16/2025 revealed that at 3:00 AM the resident was placed on the bedpan, and with digital stimulation, expelled large, formed stool.
Interview on 2/19/25 at 4:16 PM with Resident 3 confirmed that it was definitely uncomfortable when that nurse stuck (gender) finger in my butt and that the resident prefers to have a bowel movement while sitting on a bedpan and not laying in bed.
A record review of Resident 3's admission Minimum Data Set (MDS -a comprehensive assessment of each resident's functional capabilities used to develop a resident's plan of care) dated 1/30/25 revealed that the resident was admitted to the facility on [DATE], with a Brief Interview for Mental Status (BIMS - a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 12 which indicates moderate cognitive impairment, frequently incontinent of bowel, dependent for transfers, no bowel toileting program, and that constipation was not present.
A record review of Resident 3's Comprehensive Care Plan (CCP - written instructions needed to provide effective and person centered care of the resident that meet professional standards of quality care) dated 2/3/2025, revealed no focus area related to constipation.
A record review of Resident 3's Medical Administration Record (MAR) from 2/1/25 through 2/19/25 revealed that the resident did not receive any bowel meds as needed to promote a bowel movement.
A record review of Resident 3's current physician orders revealed that the resident had orders for a suppository and enema to be used if needed to promote bowel movement. Resident 3 had no other bowel medication orders to be used as needed.
In an interview on 2/19/25 at 3:47 PM, Registered Nurse (RN) - A confirmed they were not supposed to do digital stimulation on any residents.
In an interview on 2/19/25 at 3:51 PM, RN - B confirmed that digital stimulation should not be done unless the resident is a quadriplegic and cannot move their own bowels and that this resident does not have those diagnosis.
In an interview on 2/19/25 at 3:57 PM, the Clinical Care Coordinator (CCC) confirmed that digital stimulation should not have been done to this resident.
In an interview on 2/19/25 at 4:41 PM, the Director of Nurses (DON) revealed that the night nurse checked Resident 3's rectum and that BM was present. The nurse then gave the resident a suppository. It was further confirmed that the suppository was not documented as given in the resident's MAR and should have been documented.
In an interview on 2/20/25 at 8:59 AM the DON confirmed there was no staff education completed regarding bowel management, prevention of constipation or digital stimulation.
In an interview on 2/20/25 at 8:43 AM, Medication Technician (MT) - C confirmed that on the night of 2/16/25 the night nurse came out of Resident 3's room and said (gender) had digitally stimulated the resident and assisted the resident onto (gender) left side to have a bowel movement. MT - C was instructed to go back in the resident's room and check on the resident in a little bit. The resident was not on a bedpan.
In an interview on 2/20/25 at 9:25 AM, Resident 3 revealed that (gender) likes to sit up in bed on the bedpan to have a bowel movement (BM) and that he doesn't like to have a BM while laying down in bed and the nurse did not put him on the bedpan the night of 2/16/25.
A record review of the facility policy dated 1/1/2023, titled Bowel Management Policy revealed that interventions to promote bowel movements include a well balanced diet, encourage adequate fluids, encourage exercise, allow enough time for adequate evacuation and review medications causing constipation, and to check for daily stool softener.
In an interview on 2/20/25 at 11:34 AM with DON confirmed there was not a bowel assessment performed for Resident 3 and agreed that digital stimulation would cause discomfort and that no new interventions were put into place after hard stool had been identified on 2/14/25 with the resident.
In an interview on 2/20/25 at 2:04 PM Licensed Practical Nurse (LPN) - G confirmed that (gender) stuck (gender) finger approximately 1 inch into resident's 3's rectum and that the resident yelled ow during the process and LPN - G continued to insert finger to remove hard stool.
B.
A record review of Resident 1's Clinical Census dated 02/19/2025 revealed the resident was admitted to the facility on [DATE].
A record review of Resident 1's Medical Diagnosis dated 02/19/2025 revealed the resident had diagnoses of Neuromuscular Dysfunction of the Bladder (nerves controlling the bladder were damaged), Paraplegia (paralysis of the legs or lower body), and Spinal Stenosis, Lumbar Region (spinal canal narrows and compresses nerves in lower back).
A record review of Resident 1's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 01/23/2025 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a residents cognitive abilities) of 13 which indicated the resident was cognitively aware. The resident required supervision or touching assistance with personal and oral hygiene (cleaning). partial moderate assistance with lower body dressing and bathing, substantial/maximal assistance with upper body dressing, and the resident was dependent on staff for toileting and footwear. The resident had an indwelling catheter (cath)(a tube inserted in the bladder to help restore urine output).
A record review of Resident 1's Care Plan with an admission date of 01/16/2025 revealed the resident had a suprapubic (SP) )(a tube inserted in through the skin into the bladder to allow urine flow) cath related to Neurogenic Bladder (lack of bladder control due to brain, spinal cord, or nerve damage), SP cath was removed 02/05/2025 and a Foley cath was placed on 02/05/2025.
A record review of the facility's Grievance Log dated 11/25/2024 - 02/10/2025 revealed Resident 1's family/Healthcare Durable Power of Attorney (POA) )(a person designated to make medical decisions for the resident) submitted a grievance on 02/05/2025 related to Resident 1's SP cath being removed when not ordered - only ordered to remove the stitch from the SP cath and the POA was upset because the facility did not notify the POA prior to the Urologist's (a physician that specializes in the urine system) office calling the POA. The grievance was taken by the Director of Nursing (DON), but it did not reveal a time. The resolution was Foley cath placed, antibiotic started, guest okay and concerns from guest. APRN there and visited with guest and family. Family requested a transfer to another facility and was transferred on 02/06/2025. A new surgery was scheduled with Urology. Administration followed up with POA and resident doing well.
A record review of the facility's Concern Form dated 02/05/2025 revealed the same as above. The Concern Form had a Receipt Of Concern date of 02/05/2025, but did not reveal the time blank had been completed.
A record review of Resident 1's Order Summary dated 02/19/2025 revealed that the physician ordered: Please remove SP suture on 02/05/2025. One time only, for 1 day.
A record review of Resident 1's Urologist's Orders dated 01/29/2025 revealed that the Urologist ordered: Please remove SP suture on 02/05/2025 per discharge paperwork on 01/22/2025.
A record review of Resident 1's Urologist's Urologic Surgery Operative Note dated 01/22/2025 revealed the resident had a SP cath placed and the cath was secured to the skin with a suture. Suture removal in 2 weeks. Catheter to be exchanged for the first time in 6 weeks, then monthly thereafter.
A record review of Resident 1's Progress Notes dated 02/19/2025 revealed an entry on 02/05/2025 at 5:43 AM that Licensed Practical Nurse (LPN)-E removed Resident 1's SP cath and there was 900 milliliters (ml) output.
A record review of Resident 1's Progress Notes dated 02/20/2025 revealed that multiple late entries were added in Resident 1's progress notes on 02/20/2025 regarding the events that occurred on 02/05/2025.
A record review of Resident 1's Medication Administration Record and Treatment Administration Record (MAR & TAR) dated February 2025 revealed Registered Nurse (RN)-F marked completed on the 02/05/2025 at 6:00 AM order to: Please remove SP suture on 02/05/2025, one time only for 1 day.
A record review of Resident 1's Advanced Practice Registered Nurse (APRN)-D's Acute visit follow-up note dated 02/05/2025 at 8:45 AM revealed nursing did communicate that the resident was not feeling well and was concerned about having Influenza (flu). The Acute visit note revealed that APRN-D examined the resident about 11:00 AM and the resident had complaints of some dizziness, headache, body ache, and congestion. The resident was further assessed, and it was noted that the resident's SP cath was inadvertently (accidentally) removed by nursing early that morning and a dressing was covering the site. Nursing did a bladder scan, and the resident had 150 cubic centimeters (cc) per the bladder scan. A foley catheter was placed and the resident had immediate drainage of about 200cc. The Acute visit did not reveal what time the Foley cath was placed. APRN-D reported having multiple conversation with the Urology office regarding scheduling the resident to have the SP cath replaced. APRN-D did discuss the SP cath inadvertently being removed with the resident's family and POA, but it did not reveal a time for the conversation.
In a telephone interview on 02/19/2025 at 10:05 AM, Resident 1's family/POA confirmed on 02/05/2025 Resident 1 had a spinal cord injury and underwent surgery. At that time a SP cath was placed and resident spent some time at a sub-acute hospital before being transferred to the facility on [DATE]. The resident had an order that was clearly written (per conversation with staff of the facility) to remove the SP cath suture in 2 weeks, but the LPN removed the entire catheter. The POA was upset because the staff did not put another cath back in right away, the nurse that removed the SP cath didn't say anything, and no other staff that worked with the resident noticed the SP cath was removed. The POA confirmed somehow the APRN noticed it, scanned the bladder, and said there was 100 cc's in bladder. When the POA arrived at the facility, the POA told the facility the POA didn't care how much was in the bladder, they wanted something in the resident to allow the resident to urinate. The POA confirmed at 11:30-11:45 AM the APRN called the Urologist's office and the Urologist's called the POA, the facility did not. At 12:30 PM the daughter arrived at the facility and there was still no cath in Resident 1, so the POA told the staff the POA wanted a meeting with the Administrator and DON and requested a Foley cath be put in. The POA confirmed the Foley was placed within 20 minutes of that. The resident was transferred to another facility on 02/06/2025 and Resident 1 had a second surgery for a new SP cath to be inserted without sutures on 02/10/2025. The POA confirmed the resident was supposed to move back home on [DATE], but now the family is hoping to get the resident home by 03/03/2025. The POA confirmed the POA, and the resident was upset because of the pain and discomfort of have the Foley cath placed and another surgery to place another SP cath, not to mention the financial burden of the surgery and the additional time that the resident had to stay in a nursing facility.
In a telephone interview on 02/19/2025 at 10:33 AM, a staff member at the Urologist's office confirmed the order for suture removal was sent to the facility 01/29/2025, the Urologist sent an order for a Foley cath placement on 02/05/2025 at 11:51 AM, and Resident 1 underwent a new SP cath insertion surgery on 02/10/2025.
In an interview on 02/19/2025 at 2:40 PM, APRN-D confirmed that APRN-D discovered that the SP cath was pulled inadvertently. APRN-D confirmed APRN-D was shocked to discover it. The resident told APRN-D that the nurse took out the SP cath. APRN-D confirmed the resident's brace was removed and seen just a dressing there. That was about 11:30 AM. The resident just said it didn't feel good. APRN-D confirmed it was removed at 5:30 AM. APRN-D told staff to call the Urologist. APRN-D confirmed that APRN-D stepped in and facilitated the process to get the resident scheduled for replacement SP cath. APRN-D confirmed it was discovered between 11:00 AM - 11:15 AM the SP cath had been removed and the family/POA showed up at the facility at 12:30 PM. The Urologist said to put a Foley cath in, and it was not inserted until 12:30 PM - 1:00 PM. APRN-D told the staff to call the family and the Urologist when APRN-D discovered the SP cath had been removed.
In a telephone interview on 02/20/2025 at 7:05 AM, RN-F confirmed RN-F was the nurse that marked completed on the suture removal order, but RN-F was not the nurse that removed it. LPN-E was the night nurse that removed the SP cath. RN-F confirmed LPN-E told RN-F in report that the SP cath had been removed and RN-F confirmed RN-F didn't think it was supposed to be removed but went on with RN-F's day passing meds and cares for the residents. RN-F found out the SP cath was not supposed to be removed from the Clinical Care Coordinator (CCC) and Resident Assessment Instrument Coordinator (RAIC). CCC and RAIC called the Urologist's office, and the nurse was very upset and informed CCC and RAIC that a Foley cath would have to be inserted because they would not be able to get a SP cath back in Resident 1's insertion site because it had been too long at that point. CCC inserted the Foley cath. RN-C confirmed RN-C thought it was 10:00 AM - 10:30 AM when CCC and RAIC notified RN-F the SP was not supposed to be removed. The nursing assistants (NA)'s did not say anything about the cath not being there during their cares. She said the NA's were supposed to drain the bag every 2 hours or so. LPN-E came in later that same day and did mention LPN-E got wrote up and worked that night shift.
In a telephone interview on 02/20/2025 at 8:08 AM, LPN-E confirmed LPN-E was passing meds to Resident 1 and looked at the SP cath site. Resident 1 told LPN-E the resident couldn't wait until the SP cath was removed that day. LPN-E later looked at order and the order said remove SP cath. LPN-E confirmed LPN-E did not click to enlarge the order on the computer screen and did not see it said remove SP cath suture. LPN-E confirmed LPN-E did proceed to remove the suture and SP cath. Resident 1 did not question why LPN-E was removing the SP cath. LPN-E confirmed LPN-E did not realize the error until later that day when the DON called LPN-E. LPN-E came to work later that day and was talked to and written up. LPN-E was given verbal education regarding if a resident had an SP cath it was usually in forever, enlarge order to read through, and make sure LPN-E did what the order said and not what the resident said. LPN-E confirmed it was an honest mistake.
In an interview on 02/20/2025 at 1:00 PM, CCC confirmed CCC had been entering late entries in the progress notes on 02/20/2025 regarding the timelines CCC thought was accurate on the events that occurred on 02/05/2025.
In an interview on 02/20/2025 at 9:43 AM, the DON confirmed the facility did not have a following provider's order policy, that would be per best practice.
In an interview on 02/20/2025 at 11:35 AM, the DON confirmed there was not an order to remove the SP cath and it should not have been removed, just the suture that was placed in the SP cath.
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
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.04(F)(i)(5)
Based on observation, interview, and record review, the facility failed to...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.04(F)(i)(5)
Based on observation, interview, and record review, the facility failed to ensure 1 (Resident 1) of 4 sampled resident's provider and resident's representative were notified of an emergent (unexpected) significant change in medical condition. The facility census was 65.
Findings are:
A record review of the facility's undated Change In Condition Or Status Of Guest/Elder/Resident policy revealed the nurse would notify the resident's attending physician or on-call physician when there has been an accident or incident involving the resident, a significant change in the resident's physical/emotional/mental condition, a need to alter the resident's medical treatment significantly, the need to transfer the resident to a hospital/treatment center, or a discovery of injuries of an unknown source. Notification to the resident and/or representative would be made when there was a significant change in the resident's physical, mental, or psychosocial status. Except in medical emergencies, notifications will be made within 24 hours of a change occurring in the resident's medical/mental condition or status. The nurse should document pertinent information in the medical record.
A record review of Resident 1's Clinical Census dated 02/19/2025 revealed the resident was admitted to the facility on [DATE].
A record review of Resident 1's Medical Diagnosis dated 02/19/2025 revealed the resident had diagnoses of Neuromuscular Dysfunction of the Bladder (nerves controlling the bladder were damaged), Paraplegia (paralysis of the legs or lower body), and Spinal Stenosis, Lumbar Region (spinal canal narrows and compresses nerves in lower back).
A record review of Resident 1's Minimum Data Set (MDS)(a comprehensive assessment used to develop a resident's care plan) dated 01/23/2025 revealed the resident had a Brief Interview for Mental Status (BIMS)(a score of a residents cognitive abilities) of 13 which indicated the resident was cognitively aware. The resident required supervision or touching assistance with personal and oral hygiene (cleaning), partial moderate assistance with lower body dressing and bathing, substantial/maximal assistance with upper body dressing, and the resident was dependent on staff for toileting and footwear. The resident had an indwelling catheter (cath)(a tube inserted in the bladder to help restore urine output).
A record review of Resident 1's Care Plan with an admission date of 01/16/2025 revealed the resident had a suprapubic (SP)(a tube inserted in through the skin into the bladder to allow urine flow) cath related to Neurogenic Bladder (lack of bladder control due to brain, spinal cord, or nerve damage), SP cath was removed 02/05/2025 and a Foley cath was placed on 02/05/2025.
A record review of the facility's Grievance Log dated 11/25/2024 - 02/10/2025 revealed Resident 1's family/Healthcare Durable Power of Attorney (POA)(a person designated to make medical decisions for the resident) submitted a grievance on 02/05/2025 related to Resident 1's SP cath being removed when not ordered - only ordered to remove the stitch from the SP cath and the POA was upset because the facility did not notify the POA prior to the Urologist's (a physician that specializes in the urine system) office calling the POA. The grievance was taken by the Director of Nursing (DON), but it did not reveal a time. The resolution was Foley cath placed, antibiotic started, guest okay and concerns from guest. APRN (Advanced Practical Registered Nurse-APRN's are Registered Nurses who have advanced education and training in a specific area of nursing. They can diagnose and treat patients/residents, order tests and prescribe medication) there and visited with guest and family. Family requested a transfer to another facility and was transferred on 02/06/2025. A new surgery was scheduled with Urology. Administration followed up with POA and resident doing well.
A record review of the facility's Concern Form dated 02/05/2025 revealed the same as above. The Concern Form had a Receipt Of Concern date of 02/05/2025, but did not reveal the time blank had been completed.
A record review of Resident 1's Order Summary dated 02/19/2025 revealed that the physician ordered: Please remove SP suture on 02/05/2025. One time only, for 1 day.
A record review of Resident 1's Urologist's Orders dated 01/29/2025 revealed that the Urologist ordered: Please remove SP suture on 02/05/2025 per discharge paperwork on 01/22/2025.
A record review of Resident 1's Urologist's Urologic Surgery Operative Note dated 01/22/2025 revealed the resident had a SP cath placed and the cath was secured to the skin with a suture. Suture removal in 2 weeks. Catheter to be exchanged for the first time in 6 weeks, then monthly thereafter.
A record review of Resident 1's Progress Notes dated 02/19/2025 revealed an entry on 02/05/2025 at 5:43 AM that Licensed Practical Nurse (LPN)-E removed Resident 1's SP cath and there was 900 milliliters (ml) output.
A record review of Resident 1's Progress Notes dated 02/20/2025 revealed that multiple late entries were added in Resident 1's progress notes on 02/20/2025 regarding the events that occurred on 02/05/2025.
A record review of Resident 1's Medication Administration Record and Treatment Administration Record (MAR & TAR) dated February 2025 revealed Registered Nurse (RN)-F marked completed on the 02/05/2025 at 6:00 AM order to: Please remove SP suture on 02/05/2025, one time only for 1 day.
A record review of Resident 1's Activities of Daily Living (ADL) - Bed Mobility task dated 01/20/2025 - 02/06/2025 revealed on 02/05/2025 at 9:07 AM the staff performed Bed Mobility on the resident.
A record review of Resident 1's ADL - Toilet Use task dated 01/20/2025 - 02/06/2025 revealed on 02/05/2025 at 9:08 AM the staff assisted the resident with toileting.
A record review of Resident 1's Monitor - Skin Observation task dated 01/20/2025 - 02/06/2025 revealed on 02/05/2025 at 9:09 AM the staff observed the resident's skin and documented the resident did not have a new skin condition.
A record review of Resident 1's Advanced Practice Registered Nurse (APRN)-D's Acute visit follow-up note dated 02/05/2025 at 8:45 AM revealed nursing did communicate that the resident was not feeling well and was concerned about having Influenza (flu). The Acute visit note revealed that APRN-D examined the resident about 11:00 AM and the resident had complaints of some dizziness, headache, body ache, and congestion. The resident was further assessed, and it was noted that the resident's SP cath was inadvertently (accidentally) removed by nursing early that morning and a dressing was covering the site. Nursing did a bladder scan, and the resident had 150 cubic centimeters (cc) per the bladder scan. A foley catheter was placed and the resident had immediate drainage of about 200cc. The Acute visit did not reveal what time the Foley cath was placed. APRN-D reported having multiple conversation with the Urology office regarding scheduling the resident to have the SP cath replaced. APRN-D did discuss the SP cath inadvertently being removed with the resident's family and POA, but it did not reveal a time for the conversation.
In a telephone interview on 02/19/2025 at 10:05 AM, Resident 1's family/POA confirmed on 02/05/2025 Resident 1 had a spinal cord injury and underwent surgery. At that time a SP cath was placed and resident spent some time at a sub-acute hospital before being transferred to the facility on [DATE]. The resident had an order that was clearly written (per conversation with staff of the facility) to remove the SP cath suture in 2 weeks, but the LPN removed the entire catheter. The POA was upset because the staff did not put another cath back in right away, the nurse that removed the SP cath didn't say anything, and no other staff that worked with the resident noticed the SP cath was removed. The POA confirmed somehow the APRN noticed it, scanned the bladder, and said there was 100cc in bladder. When the POA arrived at the facility, the POA told the facility the POA didn't care how much was in the bladder, they wanted something in the resident to allow the resident to urinate. The POA confirmed at 11:30-11:45 AM the APRN called the Urologist's office and the Urologist's called the POA, the facility did not. At 12:30 PM the daughter arrived at the facility and there was still no cath in Resident 1, so the POA told the staff the POA wanted a meeting with the Administrator and DON and requested a Foley cath be put in. The POA confirmed the Foley was placed within 20 minutes of that. The resident was transferred to another facility on 02/06/2025 and Resident 1 had a second surgery for a new SP cath to be inserted without sutures on 02/10/2025. The POA confirmed the resident was supposed to move back home on [DATE], but now the family is hoping to get the resident home by 03/03/2025. The POA confirmed the POA and the resident was upset because of the pain and discomfort of have the Foley cath placed and another surgery to place another SP cath, not to mention the financial burden of the surgery and the additional time that the resident had to stay in a nursing facility.
In a telephone interview on 02/19/2025 at 10:33 AM, a staff member at the Urologist's office confirmed the order for suture removal was sent to the facility 01/29/2025, the Urologist sent an order for a Foley cath placement on 02/05/2025 at 11:51 AM, and Resident 1 underwent a new SP cath insertion surgery on 02/10/2025.
In a telephone interview on 02/20/2025 at 7:05 AM, RN-F confirmed RN-F was the nurse that marked completed on the suture removal order, but RN-F was not the nurse that removed it. LPN-E was the night nurse that removed the SP cath. RN-F confirmed LPN-E told RN-F in report that the SP cath had been removed and RN-F confirmed RN-F didn't think it was supposed to be removed but went on with RN-F's day passing meds and cares for the residents. RN-F found out the SP cath was not supposed to be removed from the Clinical Care Coordinator (CCC) and Resident Assessment Instrument Coordinator (RAIC). CCC and RAIC called the Urologist's office, and the nurse was very upset and informed CCC and RAIC that a Foley cath would have to be inserted because they would not be able to get a SP cath back in Resident 1's insertion site because it had been too long at that point. CCC inserted the Foley cath. RN-C confirmed RN-C thought it was 10:00 AM - 10:30 AM when CCC and RAIC notified RN-F the SP was not supposed to be removed. The nursing assistants (NA)'s did not say anything about the cath not being there during their cares. She said the NA's were supposed to drain the bag every 2 hours or so. LPN-E came in later that same day and did mention LPN-E got wrote up and worked that night shift.
In a telephone interview on 02/20/2025 at 8:08 AM, LPN-E confirmed LPN-E was passing meds to Resident 1 and looked at the SP cath site. Resident 1 told LPN-E the resident couldn't wait until the SP cath was removed that day. LPN-E later looked at order and the order said remove SP cath. LPN-E confirmed LPN-E did not click to enlarge the order on the computer screen and did not see it said remove SP cath suture. LPN-E confirmed LPN-E did proceed to remove the suture and SP cath. Resident 1 did not question why LPN-E was removing the SP cath. LPN-E confirmed LPN-E did not realize the error until later that day when the DON called LPN-E. LPN-E came to work later that day and was talked to and written up. LPN-E was given verbal education regarding if a resident had an SP cath it was usually in forever, enlarge order to read through, and make sure LPN-E did what the order said and not what the resident said. LPN-E confirmed it was an honest mistake.
In an interview on 02/20/2025 at 11:35 AM, the DON confirmed there was not an order to remove the SP cath and it should not have been removed, just the suture that was placed in the SP cath.
In an interview on 02/19/2025 at 2:40 PM, APRN-D confirmed that APRN-D discovered that the SP cath was pulled inadvertently. APRN-D confirmed APRN-D was shocked to discover it. The resident told APRN-D that the nurse took out the SP cath. APRN-D confirmed the resident's brace was removed and seen just a dressing there. That was about 11:30 AM. The resident just said it didn't feel good. APRN-D confirmed it was removed at 5:30 AM. APRN-D told staff to call the Urologist. APRN-D confirmed that APRN-D stepped in and facilitated the process to get the resident scheduled for replacement SP cath. APNR-D confirmed it was discovered between 11:00 AM - 11:15 AM the SP cath had been removed and the family/POA showed up at the facility at 12:30 PM. The Urologist said to put a Foley cath in, and it was not inserted until 12:30 PM - 1:00 PM. She told the staff to call the family and the Urologist when APRN-D discovered the SP cath had been removed. APRN-D confirmed the facility did not contact the APRN-D about the SP cath removal, APRN-D discovered it during the resident assessment.
In an interview on 02/20/2025 at 11:26 AM, the DON confirmed the resident's representative was not notified of the SP cath removal until 12:00 PM when the family arrived at the facility and had a meeting with the facility's administration. The urology clinic had notified the POA, not the facility. The DON confirmed it was less than an hour from when the facility's administration was notified of the SP cath removal until the facility notified the family. The DON confirmed it was the DON's expectation that the nurse would notify the family immediately of an emergent significant change in the resident's medical condition. The DON did not confirm the SP cath being removed was an emergent significant change, but confirmed it was not a need to call 911 situation, but it was a situation that required medical attention.
In an interview on 02/20/2025 at 1:00 PM, CCC confirmed CCC had been entering late entries in the progress notes on 02/20/2025 regarding the timelines CCC thought was accurate on the events that occurred on 02/05/2025. CCC confirmed that if the day shift nurse questioned if the SP cath was removed, RN-F should have immediately contacted the CCC, provider and resident's representative. CCC confirmed that after the CCC was notified the SP cath had been removed, they did not contact the resident's representative immediately, and they wanted to formulate a plan before contacting family between 11:20 AM and 12:30 PM. The CCC confirmed the facility formulated the plan without the resident's representative's input. CCC confirmed the resident was able to make the resident's own decisions and they told the resident during the bladder scan that they were probably going to have to re-insert the Foley cath.
Apr 2024
4 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a Level II PASARR (A Level II is necessary to confirm the in...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a Level II PASARR (A Level II is necessary to confirm the indicated Mental Illness (MI)/Intellectual Disability (ID) diagnosis and to determine whether placement or continued stay in a Nursing Facility is appropriate) was completed after receiving a new diagnosis of PTSD (Post Traumatic Stress Disorder), Major Depressive Disorder (MDD) and Anxiety Disorder, for 1 of 1 sampled residents (Resident 28). The facility identified a census of 60.
Findings are:
A record review of the demographic information dated 4/9/24 revealed that the facility had accepted Resident 28 for admission on [DATE] with a primary diagnosis of Spinal Stenosis, Lumbosacral region (when the space inside the backbone is too small causing pressure on the spinal cord).
A record review of the MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 1/29/24, Section C, revealed Resident 28 had a BIMS (Brief Interview for Mental Status, a test used to get a quick snapshot of a resident's cognitive function, scored from 0-15, the higher the score, the higher the cognitive function) score of 15 indicating Resident 28 was oriented and had no confusion.
A record review of the Level I PASARR (Preadmission Screening and Resident Review that is a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) on file dated 6/13/2020 revealed that the document indicated no MD/ID for Resident 28 at the time of admission.
A record review of the diagnosis list dated 4/9/24 revealed Resident 28 to have a PTSD diagnosis dated 8/11/23, MDD dated 8/11/23, and an Anxiety Disorder diagnosis dated 8/11/23.
An interview on 4/9/24 at 2:30 PM with the Director of Transitions (Admissions), after review of the current diagnosis list for Resident 28, confirmed that Resident 28 did have MD/ID diagnoses and should have had a level II PASARR initiated in 8/2023 and did not. The Director of Transitions voiced (gender) would initiate the level II PASARR.
An interview on 04/10/24 at 3:22 PM revealed that the Director of Transitions had initiated a level II PASARR screen for Resident 28 and voiced that Resident 28 did in fact trigger for MD/ID and the need for a level II screen.
A record review of the undated policy titled Identification Screen (PASRR) read as follows:
Policy: An identification screen will be done prior to admission to see if the gest is eligible for placement. Identification screen (PASRR) will also be completed as needed for change in diagnosis or condition.
4. Resident's will be monitored for change in condition including diagnosis changes that would require a new PASRR to be completed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09C1c
Based on record review and interview; the facility failed to review and revise t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09C1c
Based on record review and interview; the facility failed to review and revise the baseline care plan for 1 (Resident 68) of 1 sampled resident after a fall with major injury. The facility census was 60.
Findings are:
A record review of Resident 68's Medical Diagnosis sheet dated 4/9/2024 revealed the resident was admitted on [DATE] with diagnoses of ground level fall, fracture of second cervical vertebra (a bone in the neck), dorsalgia (back pain), major depressive disorder (persistently depressed mood or loss of interest in activities), congestive heart failure (the heard doesn't pump blood as well as it should), macular degeneration (loss in the center of the field of vision), osteoporosis (bones are brittle and weak), stress incontinence (involuntary, sudden loss of urine), muscle weakness, and polyneuropathy (numbness and tingling in the hands or feet).
A record review of Resident 68's discharge Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 4/1/2024 identified Resident 68 exhibited moderately impaired cognition with a Brief Interview of Mental Status (BIMS score can range from 0 to 15, with lower scores indicating a decline in cognitive performance ) score of 8 indicating Resident 68 is moderately cognitively impaired.
A record review of Resident 68's Fall Risk assessment dated [DATE] indicated the resident was at risk for falls with a score of 10.
A record review of Resident 68's Baseline Care Plan (BCP) dated 3/28/2024 indicated Resident 68 was admitted due to generalized weakness and history of a fall. The BCP further stated to encourage use of the call light prior to ambulation and to wait for assistance and to wear gripper socks.
A record review of Resident 68's Comprehensive Care Plan (CCP) that was initiated on 3/28/2024 had no focus, goals, or interventions for falls.
A record review of an Incident Report completed by the DON (Director of Nursing) dated 4/1/2024 at 12:10 PM revealed Resident 68 transferred [gender] self in the bathroom and fell reaching for the walker. The report stated Resident 68 was sent to the emergency room for evaluation and was admitted for a rib fracture. The report further revealed the plan of care will be updated with interventions for frequent checks and offer the bathroom.
A record review of Resident 68's BCP on 4/9/2024 at 9:13 AM revealed no new fall interventions after the resident's fall on 4/1/2024 with resulting rib fracture.
A record review of Resident 68's CCP on 4/9/2024 at 9:05 AM revealed no focus, goals, or interventions for falls.
A record review of Resident 68's CCP on 4/9/2024 at 4:30 PM revealed a fall focus related to confusion, deconditioning, gait/balance problems and history of falls with fall interventions in place.
An interview on 4/9/2024 at 2:30 PM with the NT-E (Nurse Tech) regarding which residents [gender] was caring for were at risk for falls on the unit, revealed [gender] was unaware that Resident 68 was at risk for falls.
An interview on 4/9/2024 at 3:20 PM with the DON and ADM (Administrator) regarding what interventions were put in to place after the fall with major injury on 4/1/2024, as they were not present on the BCP or CCP, revealed the resident had a BCP. No response was received from either the DON or ADM in response to the BCP having no updated interventions in place or that the CCP initiated 3/28/2024 had no focus on falls.
An interview on 4/10/2024 at 10:20 AM with LPN-D (Licensed Practical Nurse) regarding who can update the care plan, LPN-D stated anybody. LPN-D further revealed that if the nurse did not know how to update the care plan, the CCC (Clinical Care Coordinator)-A could assist. When asked how soon [gender] would update a care plan if [gender] had a resident fall, LPN-D said, right away.
A record review of the facility policy Fall Risk Management Policy dated 1/1/2023 stated it is the policy of the facility that patients are assessed for their level of fall risk and implement appropriate interventions to mitigate the risk of falling and/or risk of injury with falls. The policy further revealed the following:
2. Determining appropriate interventions:
e. fall risk interventions should be reviewed by the interdisciplinary team as needed and can be included in the Quality Assurance, Huddle, Risk, and/or All Team Meetings.
f. care plan interventions are reviewed during interdisciplinary team meetings assuring interventions continue to be appropriate for the patient.
g. care plan interventions should be monitored and/or audited for consistent application in the care of the patient. Care plan interventions can be listed on the MAR/TAR and/or nurse tech care plan according to the Plan of Care policy.
A record review of the undated facility policy Comprehensive Care Planning stated:
9. Assessments of guests are ongoing and care plans are revised as information about the guest and the guest's conditions change.
10.The Interdisciplinary Team is responsible for the review and updating of care plans:
a. when there has been a significant change in the guest's condition,
b. when the desired outcome is not met,
c. when the guest has been readmitted to the facility from a hospital stay.
CONCERN
(F)
📢 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
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Licensure Reference Number 175 NAC 12-006.11E
Based on observation, interview, and record review; the facility kitchen staff failed to label and date opened packages of food in the walk-in refrigerato...
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Licensure Reference Number 175 NAC 12-006.11E
Based on observation, interview, and record review; the facility kitchen staff failed to label and date opened packages of food in the walk-in refrigerator and dry storage, failed to dispose of expired food from the walk-in refrigerator, and failed to perform hand hygiene while prepping room trays for lunch to prevent the potential of spread of infection and cross contamination. This had the potential to affect all 60 residents. The facility census was 60.
Findings are:
A.
An observation on 4/8/2024 at 7:50 AM of the walk-in refrigerator revealed:
-an open box of jalapeno peppers not dated,
-an open box of lemons not dated,
-an open bag of dried out carrots not dated,
-container of lettuce dated 4/4/2024,
-an open container of coleslaw with open date of 3/29/2024 and use by date of 4/4/2024,
-an open package of baby spinach with use by date of 3/22/2024.
An observation on 4/8/2024 at 8:00 AM of the dry storage room revealed:
-a package of opened fettucine with a hole in it not dated,
-a package of opened ziti noodles closed shut with a bread tie and not dated,
-a large open bag of panko crumbs dated 3/30/2024 not closed shut sitting on top of a bin.
An interview on 4/8/2024 at 8:30 AM with the DM (Dietary Manager) confirmed that all listed above were opened packages of food that should be labeled and dated, and all the above listed expired food should not be on the shelves available for use. All expired food items were removed by the CDM at this time.
A record review of the facility policy Proper Food Storage dated 2/22/2022 stated:
2. all food products must be covered,
3. label all foods removed from their original container,
4. clearly label all food with product or item name, preparation date, use by, expiration or sell by date and prepared by,
10. perishable foods discarded after 3 days.
B.
An observation on 4/10/2024 at 11:55 AM in the kitchen revealed DA (Dietary Aide)-F lick his bare fingers with [gender]'s tongue to separate meal tickets, rub [gender] nose with the back of [gender] bare hand while prepping room trays by setting drinks on the tray, pulling desserts from the cooler and setting them on the trays, setting wrapped silverware on the trays along with the plate of food served up by the cook. DA-F then stopped to wash hands at the sink with soap and water for 10 seconds and then immediately adjusts the ball cap on [gender] head while touching [gender] hair and continued rearranging meal tickets. At 12:15 PM, DA-F washed hands at the sink with soap and water for 20 seconds. At 12:18 PM, DA-F then licks [gender] fingers again to sort meal tickets and preps additional room trays for lunch.
An interview on 4/10/2024 at 1:05 PM with the DM confirmed that DA-F should have washed [gender] hands after licking fingers and touching hair before continuing to prep room trays for lunch and was not done.
A record review of the Nebraska Food Code, 2-301.14, food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and:
A. after touching bare human body parts other than clean hands and clean, exposed portions of arms,
F. during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks,
I. after engaging in other activities that contaminates the hands.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
Licensure Reference Number 175 NAC 12-006.17D
Based on observation, record review and interview; the facility failed to perform hand hygiene to prevent the spread of infection and prevent cross contam...
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Licensure Reference Number 175 NAC 12-006.17D
Based on observation, record review and interview; the facility failed to perform hand hygiene to prevent the spread of infection and prevent cross contamination during catheter care and wound care for 1 resident (Resident 14) of 1 sampled resident. The facility census was 60.
Findings are:
A record review of Resident 14's Clinical Resident Profile printed 4/10/2024 revealed an admission date of 12/29/2023 and readmission date of 1/31/2024 with the diagnoses of multiple fractures of the pelvis and lumbosacral spine, parkinsonism (a motor syndrome that manifests as rigidity, tremors, and slow movement), chronic kidney disease (progressive damage and loss of kidne function) and an in-house acquired pressure ulcer (localized skin and soft tissue injuries that form as a result of prolonged pressure and shear, usually exerted over bony prominences) to the sacrum (a shield-shaped bony structure that is located at the base of the lumbar vertebrae and that is connected to the pelvis).
An observation on 4/10/2024 at 7:45 AM with LPN (Licensed Practical Nurse)-B and NT (Nurse Tech)-C with CCC (Clinical Care Coordinator)-A in room, revealed NT-C transfer Resident 14 from the wheelchair to the bed in preparation for catheter care and wound care. Both LPN-B and NT-C were already gowned and gloved. NT-C pulled shorts and brief down to expose the area. NT-C took several incontinence wipes out of the package and washed along the resident's groin . NT-C used additional wipes to clean the resident's genitalia. NT-C reached into the package for additional wipe to wash the catheter tubing from the meatus on down the tubing. NT-C reached into the package again for a wipe and cleaned the catheter tubing again. A wipe was sticking out of the package and NT-C poked it back into the package. NT-C then pulled a wipe out of the package and washed between the resident's legs. NT-C shut the incontinence wipes package and partially pulled the residents brief up. NT-C then removed soiled gloves. NT-C put applied clean gloves without performing hand hyigene. NT-C then emptied the urinary drain bag into a graduate per protocol and emptied the graduate into the toilet and rinsed the graduate with water and emptied into the toilet. NT-C then removed soiled gloves. NT-C applied new gloves without performing hand hyigene. Resident 14 was then positioned to [gender] side and LPN-B washed sacral area with soap and water. LPN-B removed soiled gloves and applied new gloves without performing hand hyigene. LPN-B then applied calmoseptine cream to sacral area and inner buttocks. LPN-B then removed soiled gloves and applied new gloves without performing hand hyigene. LPN-B opened a package of 4x4 dressing. LPN-B then removed gloves and applied new gloves without performing hand hyigene. LPN-B applied the 4x4 dressing to the sacral area. The resident's brief was pulled up and the resident rolled onto [gender] back. LPN-B removed soiled gloves and applied new gloves without performing hand hyigene and placed the tube of calmoseptine on back of the toilet and emptied the water bins.
An interview on 4/10/2024 at 8:15 AM with the CCC-A confirmed that no hand hygiene was completed during catheter care or wound care after removal of soiled gloves and application of new gloves. The CCC-A also confirmed that NT-C should have performed hand hygiene after washing groin and genitalia and applied new gloves before wiping down the catheter tubing. The CCC-A further confirmed NT-C should not have reached back into the incontinence wipes package with soiled gloves. The CCC-A also confirmed LPN-B did not perform hand hygiene between cleansing of sacral area and application of clean dressing.
An interview on 4/10/2024 at 8:25 AM with the ADM (Administrator) and DON (Director of Nursing) confirmed that hand hygiene should be performed between removal of soiled gloves and application of new gloves.
An interview on 4/10/2024 at 8:50 AM with NT-C revealed [gender] performed hand hygiene when [gender] entered the room and when [gender] left the room. NT-C revealed [gender] didn't realize when gloves should have been removed or when hand hygiene should have been performed. NT-C revealed [gender] didn't want to break contact with the resident by having to go near the door for hand sanitizer.
A record review of the facility policy Hand Hygiene Policy dated 2/23/2022 revealed:
A.Hand Hygiene Guidance:
1.healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications:
a. immediately before touching a patient,
b. before performing an aseptic task or handling invasive medical devices,
c. before moving from work on a soiled body site to a clean body site on the same patient,
d. after touching a patient or the patient's immediate environment,
e. after contact with blood, body fluids, or contaminated surfaces,
f. immediately after glove removal.
D. Gloves and Hand Hygiene:
1. wear gloves, according to Standard Precautions, when it can be reasonably anticipated that contact with blood or potential infectious materials, mucous membranes, non-intact skin, potentially contaminated skin or contaminated equipment occur.
2. gloves are not a substitute for hand hygiene
a. if your task requires gloves, perform hand hygiene prior to donning gloves, before touching the patient or the patient environment
3. change gloves and perform hand hygiene during patient care, if
a. gloves have been damaged,
b. gloves have become visibly soiled with blood or body fluids following a task,
c. moving from work on a soiled body site to a clean body site on the same patient or if another clinical
indication for hand hygiene occurs.
May 2023
2 deficiencies
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
LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09
Based on record review and interview, the facility failed to complete post fall neurological assessments for Resident 111. The facility census was 63.
F...
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LICENSURE REFERENCE NUMBER: 175 NAC 12-006.09
Based on record review and interview, the facility failed to complete post fall neurological assessments for Resident 111. The facility census was 63.
Findings are:
Record review of Resident 111's History and Physical dated 1/28/23 revealed the following diagnoses: Small bowel obstruction, Dementia, Diabetes and Atrial Fibrillation.
Record review of a Huddle Report revealed Resident 111 had an unwitnessed fall in the Resident 111's room on 2/14/23 at 2:00 PM.
Record review of policy and procedure with an effective date of 2/1/23 revealed neurological checks should be completed after an unwitnessed fall;
a. every 15 minutes x 4
b. every 30 minutes x 4
c. every hour x 4
d. every 4 hours x 4
e. every 8 hours x 3.
Record review of the post fall neurological checks completed after Resident 111's fall on 2/14/23 revealed the last 24 hours of neurological checks were not documented.
Interview with LPN-I (Licensed Practical Nurse) on 5/12/23 at 9:00 AM revealed the protocol post fall was to call for a nurse and perform neurological checks every 15 minutes for first hour then every 30 minutes for 2 hours, hourly for 4 hours and every 8 hours for the next 24 hours.
Interview with the DON (Director of Nursing) on 05/15/23 at 10:40 AM confirmed documentation of the every 8 hours x 3 neurological checks on Resident 111 could not be found.
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
Accident Prevention
(Tag F0689)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7a
Based on observations, interviews, and record review, the facility failed to ens...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7a
Based on observations, interviews, and record review, the facility failed to ensure bath belts were utilized to ensure safety during [NAME] pool bathing. This had the potential to effect 29 of 37 residents who received [NAME] pool baths on Wilderness Ridge North and Wilderness Ridge South. The facility census was 63.
Findings are:
Observation on 5/15/23 at 3:45 PM revealed the bath chair on Wilderness Ridge had open slots for a bath belt to slide in to. No belt was in place in the chair and no belt was observed in the tub room.
Interview of NA-F (Nursing Assistant) on 5/15/23 at 3:45 PM revealed there are slots for the use of a bath belt but belts are not used for every resident. NA-F reported having provided baths for about 4 months and was not trained to use a bath belt on any resident except for a Resident who had lower extremity amputations.
Interview with NA-H on 05/16/23 at 8:31 AM revealed NA-H was the bath aid on 5/16/23. NA-H revealed the safety belt is utilized per resident preference in the [NAME] pool bath. NA-H revealed [gender] utilized personal judgement to decide what residents would be safe without the safety belt in place during a [NAME] pool bath.
Interview of LPN-G (Licensed Practical Nurse) on 05/16/23 at 8:11 AM revealed the expectation was a safety belt was to be utilized at all times when a resident was in the [NAME] pool.
Interview with the DON (Director of Nursing) on 5/16/23 at 9:06 AM revealed the facility had no policy and procedure for the use of safety belts during whirlpool bathing. The DON revealed the facility's goal is to ensure every resident is as safe as possible.
Record review of the Manufacturer's directions for use for the Cascade Sit-bath Model # 360010-12L revealed the following:
The purpose of this manual is to provide you with a recommended procedure to help you obtain the maximum efficiency and safety from your Sit-Bath System.
Prior to the bath, perform the following preparation steps. #2. Check that the seat belt is in place and ready to strap in the Resident after they are in the tub.
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
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most Nebraska facilities.
- • 39% turnover. Below Nebraska's 48% average. Good staff retention means consistent care.
Concerns
- • 12 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
Bottom line: Mixed indicators with Trust Score of 65/100. Visit in person and ask pointed questions.
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About This Facility
What is Hillcrest Firethorn's CMS Rating?
CMS assigns Hillcrest Firethorn an overall rating of 3 out of 5 stars, which is considered average nationally. Within Nebraska, this rating places the facility higher than 99% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Hillcrest Firethorn Staffed?
CMS rates Hillcrest Firethorn's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 39%, compared to the Nebraska average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Hillcrest Firethorn?
State health inspectors documented 12 deficiencies at Hillcrest Firethorn during 2023 to 2025. These included: 1 that caused actual resident harm and 11 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Hillcrest Firethorn?
Hillcrest Firethorn is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility operates independently rather than as part of a larger chain. With 72 certified beds and approximately 59 residents (about 82% occupancy), it is a smaller facility located in Lincoln, Nebraska.
How Does Hillcrest Firethorn Compare to Other Nebraska Nursing Homes?
Compared to the 100 nursing homes in Nebraska, Hillcrest Firethorn's overall rating (3 stars) is above the state average of 2.9, staff turnover (39%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Hillcrest Firethorn?
Based on this facility's data, families visiting should ask: "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?" "Can I speak with family members of current residents about their experience?"
Is Hillcrest Firethorn Safe?
Based on CMS inspection data, Hillcrest Firethorn 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 3-star overall rating and ranks #1 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 Hillcrest Firethorn Stick Around?
Hillcrest Firethorn has a staff turnover rate of 39%, which is about average for Nebraska nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Hillcrest Firethorn Ever Fined?
Hillcrest Firethorn 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 Hillcrest Firethorn on Any Federal Watch List?
Hillcrest Firethorn 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.