Hillcrest Nursing Home

Inspectors wroteLicensure Reference Number NAC 175 12-006.11(E) Based on observation, record review, and interview, the facility failed to label frozen food packages with contents or dates. This had the potential to affect all 62 residents. A record review of a facility policy, Food Storage Policy, last revised November 2023 revealed the following:Food shall be stored at least 6 inches off the floor. All food and supplies should be stored in compliance with federal and state regulations. All foods shall be clearly labeled with contents, dated with the opening date, and discarded if not dated or expired. Frozen foods shall be dated and properly rotated. An observation on 5/04/2026 at 12:43 PM in the kitchen's walk-in freezer, the first food rack to the left revealed the following:On the 2nd shelf from the top: 2 clear unlabeled plastic bags (each bag greater than gallon-sized) of breaded food items. [...]

Inspectors wroteNebraska Reference Number 175 NAC 1-005.06(A) and 12-006.18 Based on observations, interviews and record reviews, the facility failed to have an infection control program that ensured tracking and trending was fully completed and to implement interventions for concerns that were identified to prevent antibiotic overuse, failed to utilize handwashing and gloving techniques to prevent potential cross contamination during personal care for 1(Residents 10) of 4 sampled residents. The facility identified a census of 62.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09(H)(i)(3)Based on observation, interview, and record review, the facility failed to provide assistance with oral care in accordance with the resident's assessed needs and plan of care for three (Resident 10. 37. and 40) of four sampled residents. The facility identified a census of 62. A. In accordance with the facility's policy titled: Activities of Daily Living (ADL) last revised 11/2020, under policy reads: The facility will, based on the resident's comprehensive assessment and consistent with the resident's need and choices, ensure a resident's abilities in ADLs do no deteriorate unless deterioration is unavailable. Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming and oral care. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09 & 12-006.09(H)(iv)(5) Based on record review and interview the facility staff failed to follow the bowel elimination protocol to prevent constipation for two (Resident 26 and Resident 24) of two sampled residents. The facility census was 62.

Inspectors wrote175 NAC Licensure reference number 12-006.09(H)(iii)(1), 12-006.09(H)(iii)(2)Based on record review, interview, and observations, the facility staff failed to evaluate and implement interventions to prevent additional pressure ulcer development for 1(Residents 37) of 3 sampled residents. The facility identified a census of 62. Record review of Resident 37's Minimum Data Set (MDS) (a federally mandated assessment that aids the facility in identifying a resident's care needs) dated 02/16/2026 revealed the following: Section GG: revealed toileting was coded as dependent, bed mobility required partial/moderate assistance and transfers were coded as dependentSection J: revealed use of pain medications and non-medication pain management. Section M: revealed no skin concerns noted. [...]

Inspectors wroteLicensure reference number: 12-09(H)(iv)(6)Based on observation, interview and record review, the facility failed to provide appropriate treatment and services to prevent urinary tract infections (UTIs) and maintain bladder continent for one (Resident 10) of one resident reviewed for urinary continence and infection prevention. The facility failed to implement the resident's toileting interventions despite recurrent urinary tract infections, ongoing urinary symptoms, decline in condition, and a history of urosepsis. These failures place the resident at risk for worsening infections, skin complications, discomfort, decline in continence status, and hospitalization. The facility identified a census of 62. [...]

Inspectors wroteBased on record review and interviews, the facility failed to monitor 2 (Residents 6 and 20) of 2 sampled residents for adverse effects following dialysis treatments. The faciity identified a census of 62 residents. Record review of a facility policy titled, Hemodialysis Access, dated November 2024, revealed the following:The stated purpose of the policy was to ensure safe monitoring, protection, and documentation, of dialysis access sites and prevent complications for residents receiving dialysis. The dialysis site (for example, a fistula, a surgically created connection between an artery and vein to provide long term access for dialysis) would be assessed on admission/readmission, upon return from dialysis, and with any change in condition. After residents return from dialysis, care of the fistula includes 1. Assess dressing; 2. Check for bleeding; 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 (Resident 7) of 5 residents' medication regimens were free from unnecessary bowel management medications. The facility identified a census of 62 residents. Record review of Resident 7's care plan revealed Resident 7 was admitted on [DATE] with diagnoses of coronary artery disease, atrial fibrillation (a type of irregular heart rhythm), Diabetes Mellitus Type 2 (a metabolic disorder where the body can't use insulin effectively), dementia (a progressive condition marked by the development of multiple cognitive and behavioral problems), macular degeneration (an eye disease that commonly leads to vision loss), and a history of falling. [...]

Inspectors wroteLicensure Reference Number 175 NAC 12-006.02(H)Based on record review and interview, the facility failed to thoroughly investigate a fracture for 1 resident (Resident 3) of 3 sampled residents. The facility census was 67.

Inspectors wroteLicensure Reference Number NAC 175 12-006.12(A) Based on interview and record review the facility failed to provide an indication and rationale for the use a prophylactic antibiotic for one (Resident 17) of three residents. The facility identified a census of 63.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.04D2a Based on an interview and record reviews, the facility failed to have a qualified Dietary Manager. This had the potential to affect all residents. The facility identified a census of 63 at the time of survey.

Inspectors wroteLicensure Reference Number 175 NAC12-006.11E Based on observations, interviews, and record review, the facility kitchen staff failed to store food under sanitary conditions, complete hand hygiene while preparing and serving food, and maintain proper freezer temperatures to keep frozen foods solid. This had the potential to affect all residents. The facility identified a census of 63 at the time of the survey.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.11D Based on observations, interviews, and record reviews, the facility failed to follow a recipe in a method to preserve nutritive value. This had the potential to affect all residents who consumed these meals. The facility had identified a census of 63 at the time of survey.

Inspectors wroteLicensure Refeference Number 175 NAC 12-006.09 Based on observation, interviews and record review, the facility failed to implement measures for a contracture of the left hand for 1 (Resident #26) of 1 sampled resident.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.09D7b Based on observations, interviews, and record review, the facility failed to implement interventions and ensure the resident's environment was free from accident hazards to reduce the risk of falls. This affected 1 (Resident 472) of 3 sampled residents. The facility had identified a census of 63 at the time of the survey.

Inspectors wroteLicensure Reference Number 175 NAC 12-006.17D Based on observation, interview, and record review, the facility failed to implement the required infection prevention and control practices while administering medications to 3 (Residents 25, 28, and 466) of 4 sampled residents. The facility census was 63.