Hillcrest Country Estates-Cottages

Inspectors wroteLicensure Reference Number 175 NAC 12-006.12(A)(vi) Based on interviews and record reviews; the facility failed to ensure pharmacy recommendations were completed for 3 (Residents 5, 8, and 9) of 5 sampled residents. The facility staff identified a census of 47.

Inspectors wroteNebraska Licensure Reference Number 175 NAC 12-006.11(A)(i) Based on observations, interviews, and record reviews; the facility failed to follow the menu to assure nutritional value of foods in 1 (Cottage 70) of 3 cottages. This had the potential to affect 13 residents receiving foods from that kitchen. The facility staff identified a census of 47.

Inspectors wroteNebraska Licensure Reference Number 175 NAC 12.006.11(A)(i) Nebraska Food Code 2017 4-602.11(D)(5) Based on observations, interviews, and record reviews; the facility failed to ensure the cleanliness of a reach-in freezer in Cottage 80 and a reach-in refrigerator in the Rehab Cottage to prevent the potential for foodborne illness. This had the potential to affect 13 residents who received food in Cottage 80 and 21 residents who received food in the Rehab Cottage. The facility staff identified a census of 47.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04(B)(ii)(1) Based on interview and record review the facility failed to ensure nursing assistants received annual abuse and dementia training for 5 of 5 employee files reviewed. The facility census was 47.

Inspectors wroteBased on record review and interview the facility failed to ensure a baseline care plan was completed in 48 hours after Resident 59 was admitted to the facility. The resident was 1 of 12 residents surveyed. The facility had a census of 47.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09 & 12-006.09(H)(iii) Based on record review and interview the facility failed to monitor for neurological changes after a head injury and failed to evaluate and monitor changes in skin integrity for 1 (Resident 47) of 1 residents sampled and failed to follow physician's orders for 1 (Resident 58) of 9 residents sampled. The facility census was 47.

Inspectors wroteBased on interviews and record reviews, the facility failed to identify specific behavioral symptoms for the continued use of antidepressant medications for 2 (Residents 5 and 9) of 5 sampled residents. The facility staff identified a census of 47.

Inspectors wroteNebraska Licensure Reference Number 175 NAC 12-006.04(F)(i)(5) Based on interviews and record reviews; the facility failed to notify the physician of a resident's laboratory result for 1 (Resident 8) of 5 sampled residents; and the facility failed to notify the resident's representative and physician of a head injury for 1 (Resident 47) of 1 sampled resident. The facility staff identified a census of 47.

Inspectors wroteLicensure Reference Number 12-006.02(H) and St 28-372 Based on record review and interview the facility failed to submit an investigation report on an injury of unknown origin to the state agency in 5 working days for 1 (Resident 47) of 2 residents sampled the facility census was 47.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.10B1 Licensure Reference Number 175 NAC 12-006.10B1a Licensure Reference Number 175 NAC 12-006.10D1 Based on observations, record review, and interview: the facility failed to administer medications while keeping a medication error rate not 5% or greater which affected 4 (Resident 9, 7, 8, and 2) of 6 sampled residents. The medication error rate was 9.8%. The facility census was 117.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.10D Based on observations, record review, and interview; the facility failed to follow the five rights of medication administration causing significant medication errors which affected 2 (Resident 2 and 9) of 3 sampled residents. The facility census was 117.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.12E1, Licensure Reference Number 175 NAC 12-006.12E1a, Licensure Reference Number 175 NAC 12-006.12E3 Based on observation, record review and interview; the facility failed to provide safe storage of drugs and biologicals as medications were left in unlocked medication cabinets in rooms [ROOM NUMBERS] in Cottage 70, both of which were occupied with a resident; failed to have a scheduled II medication under double lock and in original container with label in Resident 2's room; and failed to have a schedule eye drop in original container with label in Resident 8's room. The facility census was 117.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.17B Licensure Reference Number 175 NAC 12-006.17D Based on observation, record review, and interviews; the facility failed to perform hand hygiene to prevent the potential of cross contamination between residents during morning and evening medication pass. This had the potential to affect 3 (Resident 9, 7, and 8) out of the 6 sampled residents. The facility census was 117.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11E Based on observations, record reviews and interviews; the facility failed to ensure foods were labeled and dated in the refrigerators and dry storage areas in all 3 cottages, failed to ensure that scoops were not in flour and sugar bins in cottage 80, failed to ensure foods were not on the floor in cottage 80 to prevent cross contamination, failed to store resident food items in a separate fridge from facility food in all 3 cottages, failed to perform hand hygiene between glove changes to prevent cross contamination during meal prep in all 3 cottages, failed to sanitize thermometer between foods in the rehab and cottage 80, failed to store equipment in a manner to prevent contamination on surfaces of the equipment in the rehab cottage and failed to maintain cleanliness of backsplash on stove and under stove in rehab cottage. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12.006.02(8) Based on observation, record review and interview; the facility failed to report allegations of abuse /neglect/ significant injury within the required timeframe to Adult Protective Services [APS] and the Department of Health and Human Services [DHHS] for 5 (Residents 11, 23 43, 93 and 94) of 14 facility investigations reviewed. The facility census was 48.

Inspectors wroteLicensure Reference Number 175 NAC 12.006.17B Licensure Reference Number 175 NAC 12.00617D Based on observation, interview, and record review, the facility staff failed to utilize handwashing and gloving techniques during the provision of cares and treatments for 2 (Resident 13 and 44) of 9 sampled residents. The facility census was 48.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D2b Based on observation, interview, and record review, the facility staff failed to evaluate, monitor, ensure consistent documentation related to measurements of a pressure ulcer for 1 (Resident 13) of 3 sampled residents. The facility census was 48.

Inspectors wroteLicensure Reference: 175 NAC 12-006.09D7 Based on observation, interview, and record review, the facility failed to evaluate falls for potential causal factors and implement interventions to prevent falls for 1 [Resident 2] of 3 sampled residents. The facility had a total census of 47.

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.17D Based on observation, record review and interview, the facility failed to 1) ensure respiratory equipment was cleaned, dried, and stored in a manner to prevent the potential for cross contamination and 2) ensure that hand hygiene was completed between glove changes and medication administration. This has the potential to affect 13 of 13 residents in the 800 cottage and 12 of 12 residents in the 700 cottage. The facility identified the census to be 46. FINDINGS ARE: A. A record review of the Physician's Orders list ran on 3/15/23 revealed Resident 29 had the following orders: [...]

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.05(5) Based on record review and interview, the facility failed to ensure a written notice of transfer was completed and provided to the representative at the time of transfer to the hospital for 1 of 2 sampled residents (Residents 29). The facility identified a census of 46.

Inspectors wroteBased on record review and interview, the facility failed to obtain a signed bed-hold policy at the time of transfer to the hospital for 1 of 2 sampled residents (Residents 29). The facility identified a census of 46. FINDINGS ARE: A record review of the Progress Notes dated 3/16/22 through 3/16/23 revealed Resident 29 had been hospitalized [DATE] through 11/27/22 due to chest pain. An interview on 03/20/23 at 02:36 PM with RN-D (Registered Nurse) confirmed that there was no bed-hold policy notice for Resident 29. A record review of the undated facility policy titled Bed Hold Policy reads as follows; 1. Prior to Hillcrest Country Estates transferring a guest to a hospital or allowing a guest to go on therapeutic leave, Hillcrest Country Estates must provide written information to the guest or legal representative that specifies: a. [...]

Inspectors wroteLICENSURE REFERENCE NUMBER 175 NAC 12-006.04C Based on interview and record review, the facility failed to ensure sufficient staffing to prevent call light response times of greater than 60 minutes for Residents 8 and 24. The sample size was 13. The facility census was 46. FINDINGS ARE: A. During an interview on 03/16/23 at 09:46 AM, Resident 8 voiced that (gender) independently keeps a call light log due to long call light response times and reported that this am that the call light had been activated at 06:59 AM and not answered until 08:22 AM. [...]