Eastmont

Licensure Reference Number: 175 NAC 12-006.09(H)(vi)(3) Based on record review and interview, the facility failed to ensure 3 (Residents 2, 6, and 8) of 6 sampled residents were provided with oxygen in accordance with physician orders. The facility had a total census of 19 residents. Findings are:Record review of Weights and Vitals Summary dated 03/28/2026 at 7:02 AM revealed that Resident 2 had an oxygen (O2) saturation (the percentage measurement of oxygen circulating in the blood) of 89% on room air (RA). Record review of Mayo Clinic definition of hypoxemia (low levels of oxygen in the blood) considers oxygen saturation values under 90% to be low (https://www.mayoclinic.org/symptoms/hypoxemia/basics/definition/sym-20050930). Record review of Resident 2's The Administration Record revealed Resident 2 had an order to apply oxygen to keep oxygen saturations greater than 90% as needed for decreased O2 saturations. Record review of Progress Notes dated 03/28/2026 charted by Registered Nurse (RN) revealed that 911 was called at 7:15 AM and Resident 2 left the facility at 7:41 AM. An…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09Based on record reviews and interviews, the facility failed to ensure all orders that were prescribed by a medical practitioner for the use of oxygen when needed, were entered into the resident's Order Summary for 2 (Resident 5 and Resident 6) of the 6 residents sampled . The facility census was 19. Findings are: Record review of Resident 5's admission Record dated 04/14/2026 revealed that the resident was originally admitted to the facility on [DATE] with a diagnosis of a pulmonary embolism (a sudden and dangerous blockage of one of the lungs arteries caused by a blood clot). Record review of Resident 5's admission Orders dated 12/18/2025 revealed an order, signed by the resident's Primary Care Provider (PCP) for oxygen as needed to keep sats (blood oxygen saturation) 90%.Record review of Resident 5's Order Summary dated 12/30/2025 revealed no order for oxygen to be administered as needed to keep blood oxygen saturation at 90%. Record review of Resident 6's admission…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure reference number 175 NAC 12-006.11C Based on interviews, record review, and observations, the facility failed to ensure kitchen staff wore hairnets and beard nets, performed hand hygiene for 20 seconds and hand hygiene between glove changes, and failed to ensure the food is labeled and dated, and inside of ice machine was clean to prevent food-borne illness. This had the potential to affect all 17 residents who ate out of the kitchen. The facility census was 17. Findings are:Record review of Eastmont Towers Community Handwashing policy and procedure dated 2/1/2017 revealed: Dietary staff will hand wash hands before starting work, when returning to work, after smoking, eating, drinking and visiting restrooms, using phones and handling money, after handling garbage or chemicals and at other times when hands have been soiled. -Procedure: Turn on faucet with warm running water. Wet hands and apply soap. Rub your hands together to make a lather. Scrub well for at least 20 seconds. Pay attention to your wrist, back of hands, between fingers and under fingernails. Rinse your…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 12-006.04(A)(iii)Based on record review and interview, the facility failed to ensure 2 (Medication Aide (MA) L and M) of 5 employees sampled Adult/Child background check was completed. This has the potential to affect all residents that reside in the facility. The facility census was 17. Findings are:Record review of Staff names, seniority dates, and department list dated 8/6/25 revealed MA-L's start of employment was 9/5/23. Further record review of MA-L's personal records revealed no documentation of an Adult/child central registry. Record review of Staff names, seniority dates, and department list dated 8/6/25 revealed MA-M's start of employment was 12/20/23. Further record review of MA-M's personal records revealed no documentation of an Adult/child central registry. An interview on 8/7/25 at 1:10 PM with HR confirmed there was not any Adult/child central registry form in MA-L and MA-M personal records. Record review of Eastmont Hiring Process policy dated 6/28/2019 revealed: Purpose: Eastmont is committed to hiring the best person to provide…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Licensure Reference Number 175 NAC 12-006.18(B)Based on observations, record review, and interviews, the facility failed to ensure infection control practice with hand hygiene during resident care, medication administration, and housekeeping to prevent cross contamination with 2 (Residents 6 and 22) of 3 sampled residents . The facility census was 17. Findings are:A record review of the facility policy titled Handwashing/Hand Hygiene. Revision date of 8/30/2024 revealed the following: Policy Statement. This facility considers hand hygiene the primary means to prevent the spread of infections. Policy Interpretation and Implementation. All personnel shall follow the handwashing or the hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hand rub, etc.) shall be readily accessible and convenient for staff use to encourage compliance with hand hygiene policies. Wash with soap and water when hands are visibly soiled. Wash with soap and water or use an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.11(E) Based on observations, record review, and interviews, the facility failed to maintain the exhaust hood over the cooking area in clean and sanitary conditions to prevent the potential for food-borne illnesses. This had the potential to affect all residents who ate food served from the kitchen. The facility census was 17. Findings are: An observation on 07/29/2024 at 9:10 AM during the initial brief tour of the kitchen revealed the exhaust hoods over the cooking areas were coated with a dark brown substance. In an interview on 07/29/2024 at 9:10 AM, the Dietary Manager (DM) confirmed the exhaust hoods over the cooking area were not clean. The DM revealed that twice a year, an external company comes out to clean them. A review of the 2017 Nebraska Food Code 4-601.11 Equipment, Food-Contact Surfaces, Nonfood- Contact Surfaces, and Utensils, revealed: (C) Nonfood-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.18 (C) Based on observation, record review, and interviews, the facility failed to ensure hand hygiene was performed in a manner to prevent the potential for cross contamination during peri-cares (washing the genitals and anal area) for Resident 16. This affected 1 resident sampled for urinary tract infections (UTIs). The facility census was 17. Findings are: A review of Resident 16's admission Record printed 07/30/2024 revealed the resident was admitted on [DATE] with diagnoses of heart attack, heart failure, Alzheimer's disease, rhabdomyolysis (a condition in which damaged muscle breaks down quickly and releases potential toxins into the blood), high blood pressure, and anxiety. A review of an SBAR [Situation-Background-Assessment-Recommendation, a tool used for communicating with a medical provider] Tool for Suspected Urinary Tract Infection) dated 097/19/2024 revealed the nurse reported symptoms of increased urinary incontinence, urgency, and frequency, and received…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D Based on interview and record review, the facility failed to ensure residents were free from unnecessary medications related to medication being given outside of the physician ordered parameters for 1 (Resident 5) of 2 sampled residents. The facility identified a census of 16. Findings Are: A record review of Resident 5's MAR (Medication Administration Record) dated July 2023 revealed Resident 5 was taking the following medication; Midodrine (a medication which causes the blood vessels to tighten, which increases blood pressures) 10 milligrams (MG) 1 tablet three times daily for hypotension and medication should be held for systolic blood pressure (SBP (systolic blood pressure which indicates the pressure caused by your heart contracting and pushing out blood)) greater than 140. A record review of the MAR's dated July 2023, June 2023 and May 2023 revealed the Midodrine which had parameters to hold if SBP was greater than 140, had been given outside of ordered parameters on the following days; 6/4/23 at 12:00 PM with a documented B/P…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY LICENSURE REFERENCE NUMBER 175 NAC 12-006.11A2 Based on interview, observation, and record review, the facility failed to provide fluids to meet the ordered restrictions for 1 (Resident 5) of 1 sampled resident. The facility identified a census of 19. Findings Are: A record review on 7/10/23 of Resident 5's demographic information revealed Resident 5 admitted to the facility on [DATE]. A record review on 7/10/23 of the diagnoses list revealed Resident 5 had diagnoses of ESRD (End Stage Renal Disease) dated 10/26/20 and Chronic Kidney Disease and Resident 5 was receiving dialysis treatments. A record review of the MDS (Minimum Data Set, a comprehensive assessment of each resident's functional capabilities) dated 5/5/23 revealed Resident 5 had a BIMS score ( 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) of 14 which indicated Resident 5 was cognitivley intact. The MDS revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.