Crest View Care Center

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(I) Based on record review and interview, the facility failed to determine root causes of falls and implement interventions of these identified risks to prevent fall from recurring for 1 (Resident 13) of 2 sample residents. The facility identified a census of 29.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11(E) Based on observations, interviews, and record reviews, the facility failed to dispose of expired foods, ensure hair was restrained in areas where food was prepared, and wash dishware at the required temperature to prevent the potential for foodborne illness for all residents in the facility. The facility census was 29. Findings Are: A.An observation on 12/01/2025 at 10:05 AM in the facility's dry storage room revealed the following items:-A jug of Sysco Classic Worcestershire Sauce which had an opened-on date of 7/22/2025 and was about 1/3 used. The jug had a Best By date of October 30, 2025. -Several cans of evaporated milk that had manufacture dates of 4/3/2024 and no expiration date. They were marked as being received on 10/1/2024. -13 cans of Casa Solana Sweetened Condensed Milk with expiration dates of 10/4/2025. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.18 Based on record review and interview, the facility failed to ensure they employed a qualified infection preventionist. This had the potential to affect all residents. The facility census was 29. Findings Are: A record review of a Professional Staff document provided by the facility on 12/1/2025 revealed the facility's infection preventionist was the administrator. An interview on 12/8/25 at 1:40 PM with the Administrator confirmed the administrator was the facility's infection preventionist despite not possessing the qualifications required by regulation to fill this role. The administrator also confirmed the facility's Corporate Nurse Consultant had been assisting with the facility's infection control program remotely from another state, which did not meet regulatory requirements.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04(B)(ii)(1)Based on record review and interviews, the facility failed to ensure 1 of 5 sampled nurse aides completed 12 hours of annual ongoing training. This had the potential to affect all 29 residents who resided within the facility.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.02(D) Based on record reviews and interviews, the facility failed to protect the residents' right to be free from physical and verbal abuse by another resident for 4 (Residents 2, 24, 27 and 32) of 4 sampled residents. The facility identified a census of 29.

Inspectors wroteBased on record review and interviews, the facility failed to attempt, implement, and document non-pharmacological interventions prior to administering an as needed (PRN) antipsychotic medication for Resident 13; failed to ensure PRN antipsychotics were not continued beyond 14 days for Residents 2 and 13; and failed to ensure as needed psychotropic medications were not continued past 14 days without a rationale for Resident 2 and 28. The sample size was 5 and the facility census was 29. Findings Are: A record review of the facility policy Antipsychotic Use Policy and Procedure dated November 2022 revealed a policy statement To ensure neuroleptics, hypnotic, sedative, antidepressant, anxiolytic, and antipsychotic medications will be used only when it is necessary to treat a specific condition. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.02(H) Based on record review and interview, the facility failed to initiate investigations of potential abuse, complete thorough investigations of alleged violations, and maintain documentation of the investigations, for 5 (Resident 2, 13, 24, 27, and 32) of 5 sample residents. The facility identified a census of 29.

Inspectors wroteThe facility failed to ensure the attending physician reviewed the monthly pharmacist recommendations and documented in 3 (Residents 2, 13, and 28) of 5 sampled residents' medical record that the identified irregularity had been reviewed and what, if any, action had been taken to address it. The facility census was 29. Findings Are: A. A record review of Resident 2's admission Record dated 12/4/2025 revealed the resident was admitted to the facility on [DATE]. A record review of Resident 2's order summary revealed the resident had the following psychotropic medication orders: -Ativan (an antianxiety medication) oral tablet 0.5 milligrams (MG), give 1 tablet by mouth every 30 minutes as needed for anxiety or shortness of breath. The order had a start date of 10/22/2025. [...]

Inspectors wroteBased on record review and interview, the facility failed to notify the ombudsman of a discharge for 1 (Resident 37) of 1 sampled resident. The facility census was 29. Findings Are: A record review of Resident 37's admission Record dated 12/3/2025 revealed the resident was admitted to the facility on [DATE] and was discharged from the facility on 9/26/2025. A record review of Resident 37's Progress Note dated 9/26/2025 revealed the resident was discharged from the facility and left with their child and personal belongings. An interview on 12/2/25 at 2:05 PM with Social Services (SS) revealed SS did not send notifications to the ombudsman for any resident who had a planned discharge and as such, had not notified the ombudsman of Resident 37's discharge.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(E) Based on record review and interview, the facility failed to develop a comprehensive care plan (CCP, a document that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment) regarding Activities of Daily Living (ADLs, tasks related to personal care, such as dressing, eating, and mobility) for 1 (Resident 1) of 13 sampled residents. The facility identified a census of 29.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.12(D)(vi) Based on observation, record review, and interview; the facility failed to ensure a medication cassette reflected the correct administration time for 1 (Resident 27) of 6 sampled residents. The facility census was 29. Findings Are: A record review of the facility policy Labeling of Medications and Biologicals dated 2025 revealed all medications and biologicals used in the facility will be labeled in accordance with current state and federal regulations to facilitate consideration of precautions and safe administration of medications. A record review of the facility policy Medication Reconciliation Policy dated December 2022 revealed the facility would verify medication labels match physician orders and consider rights of medication administration each time a medication is given. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11(D) Based on observation, record review, and interview; the facility failed to ensure nutritive value was maintained for 2 (Residents 24 and 28) of 2 sampled residents who received pureed meals. The facility census was 29. Findings Are: A record review of a facility provided document Dining Manager- Pureed Beef & Broccoli Stir Fry dated 2025 revealed serving size options for 5, 10, and 20 servings. The ingredients for preparing 5 servings of the dish were:-1 quart and 1 cup of Beef & Broccoli Stir Fry,-1 teaspoon of beef base, and-3/4 cup of water. A record review of a facility provided bag revealed the bag contained Trio Low Sodium [NAME] Gravy Mix. The back of the bag contained preparation instructions which stated to make 2 cups of gravy, 1/2 cup of gravy mix should be prepared with 2 cups of water. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H) Based on observations, interview, and record review, the facility failed to provide services to maintain the personal hygiene for 1 (Resident 3) of 4 sampled residents. The facility identified a census of 30.

Inspectors wroteLicensure Reference 175 NAC 12-006.09(H)(iii)(2) Based on record reviews and interviews, the facility failed to provide monitoring of pressure ulcers (a localized injury to the skin and underlying tissue caused by prolonged pressure on a specific area of the body, often occurring over bony prominences like the heels, hips, or tailbone, leading to tissue damage and potential open sores if left untreated; this typically happens in people who are immobile or confined to a bed or wheelchair for extended periods) and treatments for the pressure ulcers as ordered for 1 (Resident 1) of 2 sampled residents. The facility identified a census of 30.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11(E) Based on observation, interview, and record review; the facility failed to ensure sanitary conditions in the kitchen and that food was used or discarded before their expiration dates to prevent the potential for foodborne illness. This had the potential to affect all 31 residents who ate from the kitchen. The Findings Are: A record review of facility policy Sanitation Inspection with copyright date of 2024 revealed all food service areas would be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies, and other insects. An initial kitchen tour conducted on 8/28/24 at 9:06 AM revealed the following observations: [...]

Inspectors wroteBased on observation, interview, and record review; the facility failed to ensure there were no flying insects in the kitchen. This had the potential to affect all 31 residents who ate food prepared within the kitchen. The Findings Are: A record review of 2017 Nebraska Food Code, under section 6-501.111 revealed the premise shall be maintained free of insects. A record review of facility policy Pest Control Policy with revision date of March 2019 revealed that the environment would be monitored by facility staff and that there was to be an emphasis on the pest control program in the kitchen. A record review of facility policy Sanitation Inspection with copyright date of 2024 revealed that all food service areas shall be kept clean, sanitary, free from litter, rubbish and protected from rodents, roaches, flies, and other insects. [...]

Inspectors wroteLicensure Reference 175 NAC 12-006.04(B)(i) Based on record reviews and an interview, the facility failed to ensure five out of five sampled employees had completed initial orientation as required. This had the potential to affect all residents who resided at the facility. The facility identified a census of 31.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.12(A)(vi) Based on record review and interview; the facility staff failed follow up on recommendations by the facility pharmacist and failed to obtain the rational for dosage reductions for 4 (Resident 6, 14, 19 and 27) of 5 sampled residents. The facility staff identified a census of 31.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09 Based on record review and interview; the facility staff failed to follow up on a gradual does reduction (GDR) for psychotropic medications for 2 (Resident 6 and 27) and failed to obtain the rational for the continued use of an as needed (PRN) medication that exceeded 14 days for 2 (Resident 17 and 27) of 5 sampled residents. The facility staff identified a census of 31. The Findings Are: A. A record review of facility policy Antipsychotic Use Policy and Procedure with revision date of November 2022, revealed a policy statement To ensure neuroleptics, hypnotics, sedative, antidepressant, anxiolytic, and antipsychotic medications will be used only when it is necessary to treat a specific condition. [...]

Inspectors wroteLicensure Reference 175 NAC 12-006.04(B)(ii)(1) Based on record reviews and an interview, the facility failed to ensure 12 hours of continuing education had been completed for 3 of 5 sampled employees. This had the potential to affect all residents who resided at the facility. The facility identified a census of 31.

Inspectors wroteLicensure Reference 175 NAC 12-006.05(S) Based on observation, interview, and record review; the facility failed to protect resident dignity and right to privacy by ensuring privacy during personal cares for 1 (Resident 13) of 4 sampled residents. The facility identified a census of 31.

Inspectors wroteLicensure Reference 175 NAC 12-006.04(F)(i)(5) Based on interviews and record reviews, the facility failed to notify the physician of significant weight loss for 2 (Resident 17 and 21) of 2 sampled residents. The facility identified a census of 31.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(B) Based on record review and interview, the facility failed to accurately document falls with major injury for 1 (Resident 27) of 12 sampled residents and to accurately document antiplatelet use for 1 (Resident 6) of 12 sampled residents in their Minimum Data Set (MDS), a federally mandated comprehensive assessment tool used for care planning. The facility census was 31. The Findings Are: A. A record review of the Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, a document published by the Centers for Medicare & Medicaid Services (CMS) to facilitate accurate and effective resident assessment practices in long-term care facilities, revealed that major injuries were those that resulted in bone fractures, joint dislocations, closed head injuries with altered consciousness, and subdural hematomas. [...]

Inspectors wroteBased on record reviews and interview, the facility failed to develop interventions after falls for 1 (Resident 17) of 2 sampled residents. The facility identified a census of 31.

Inspectors wroteLicensure Reference 175 NAC 12- 006.09(H)(i)(3) Based on observations, interviews, and record reviews; the facility failed to provide assistance with toileting and incontinence care for 2 (Resident 13 and 17) of 2 sampled residents. The facility identified a census of 31.

Inspectors wroteLicensure Reference 175 NAC 12- 006.09(I) Based on observations, interviews, and record reviews; the facility failed to ensure fall interventions were being implemented to prevent falls for 1 resident (Resident 17) and ensure safety during wheelchair locomotion with the use of footrests to prevent the potential for injury for 1 resident (Resident 13). The sample size was 3. The facility identified a census of 31.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(J) Licensure Reference Number 175 NAC 12-006.09(J)(i)(1) Based on observations, record review and interview; the facility staff failed to implement interventions to manage weight loss for 2 (Resident 12 and 21) of 3 sampled residents. The facility staff identified a census of 31. The Findings Are: A. A record review of a facility policy Nutrition Unplanned Weight Loss Clinical Policy with a last revised date of March 2019 revealed a 5% weight loss in one month was significant. Under section Recording Weights and Follow-Up, the policy revealed nursing would notify the MD (the resident's medical provider) of the weight change. The policy also revealed in the Treatment/Management section that the staff and physician would identify pertinent interventions based on identified causes and overall resident condition, prognosis, and treatment wishes. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H) Based on record review and interview, the facility staff failed to assess 1 (Resident 19) of 2 sampled resident's pain. The facility census was 31. The Findings Are: A record review of facility policy Pain Assessment and Management Policy with revision date of June 2021 revealed pain management is a multidisciplinary care process that includes assessing the potential for pain, effectively recognizing the presence of pain, identifying the characteristics of pain, addressing the underlying causes of the pain, developing and implementing approaches to pain management, identifying and using specific strategies for different levels and sources of pain, monitoring for the effectiveness of interventions, and modifying approaches as necessary. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H) Based on record review and interviews, the facility failed to assess 1 (Resident 25) of 1 sampled resident's dialysis access port site daily. The facility census was 31. The Findings Are: A record review of a facility policy Dialysis with revision date of March 2019 revealed that the facility was to monitor the resident's access site for signs or infection at least daily. A record review of Resident 25's Minimum Data Set (MDS), a federally mandated comprehensive assessment tool used for care planning, dated 5/23/24 revealed Resident 25 had a diagnosis of end stage renal disease and was receiving dialysis (a treatment that removes waste and extra fluid from the blood when the kidneys are no longer functioning properly). [...]

Inspectors wroteLicensure Reference 175 NAC 12-006.18(B) Based on observation, interview, and record review; the facility failed to ensure infection control practices were implemented for oxygen administration for 1 (Resident 6) of 1 sampled residents. The facility identified a census of 31.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.02(8) Based on record review and interview, the facility failed to submit their investigation of a fall with major injury to the state agency within five working days for 3 (Residents 1, 2, and 3) of 4 sampled residents. The facility census was 34. The Findings Are: A record review of the facility policy, Abuse Prevention Policy and Procedure dated December 2022, revealed in the investigation section that the facility will investigate all incidences such as falls, bruises, medication errors, resident complaints, etc. The Reporting and Response section revealed that the Administrator, DNS, or Nursing Supervisor will make sure that a report is filed, that the internal investigation begins immediately, and the appropriate reporting takes place. [...]

Inspectors wroteLicensure Reference 175 NAC 12-006.09D7(3) Based on interviews and record reviews, the facility failed to implement interventions to reduce falls for 1 (Resident 1) of 3 sampled residents. The facility identified a census of 34.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.11E Based on observations, interviews, and facility policy and document review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety and to prevent foodborne illness. Specifically, the facility failed to keep the food items on the steam table at temperatures of 135 degrees Fahrenheit (F) or above, failed to ensure residents were not served food items from the steam table that were lower than 135 degrees F, failed to ensure food temperatures were recorded and food temperature logs were kept, and failed to date and label opened food items. This had the potential to affect all residents that received food items from the kitchen.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.09D7a Based on observation, record review, and interview, the facility failed to ensure staff observed residents take their medication to prevent accidents. This affected 1 (Resident #26) of 1 resident observed to have been given medication by a staff member who did not observe the resident take the medication before leaving the room.