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Hillcrest Millard LLC

13225 Westwood Lane, Omaha, NE 68144 · For profit - Limited Liability company · 76 certified beds · (531) 365-3000 Medicare & Medicaid certified

Call the home — (531) 365-3000 Need help choosing, fast? Free, unbiased: Eldercare Locator 1-800-677-1116
Abuse-prevention, restraint, or reporting citation — no harm found (F0609) — cited Feb 2026Behavioral-health or dementia-care citation — no harm found (F0758)
Insights

The public record raises real questions here. Weigh the concerns below carefully.

In its favor
  • no federal fines or payment denials on record
  • fewer deficiencies at its most recent standard inspection than at the one before — a sign of improvement
Worth asking about
  • it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0609) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
  • a high number of inspection citations overall (26) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
  • its facility-reported quality-measure score sits well above its independent inspection score
  • its independent health-inspection rating is low (2/5)
  • its payroll-based staffing rating is low (1/5)
  • nursing-staff turnover (77%) runs well above the national median (45%)
  • about 27% of its spending goes to commonly-owned related companies

One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.

A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.

1/5
CMS overall
1 of 5
Health inspectionSurveyor-assigned, ranked within your stateInspector-verified 2 of 5
StaffingFrom payroll records (PBJ) 1 of 5
Quality measuresSelf-reported by the facility 4 of 5

Worth a closer look. This home's quality-measure rating runs 2 stars above its independent health-inspection score. The inspection is done by state surveyors; the quality-measure score leans on data the facility reports about itself — so a gap this large is worth reading the inspection record for.

Location & what’s nearby

Hospital
Emergency dept. usually open 24/7 · ER 24/7
Urgent care / clinic
Aobo A Du0.3 mi
13315 W Center Rd Ste 100 · (402) 717-9400 · Call to confirm hours
Pharmacy
13315 W Center Rd · (402) 717-9410 · Call to confirm hours
Grocery
3720 S 132nd St · (402) 333-4636 · Call to confirm hours
Park
13434 Kingswood Dr · (402) 444-5900 · Typically dawn to dusk
Place of worship
13326 A St · (855) 571-0200

Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Overall quality measures 4 of 5
Long-stay residentspeople who live here 5 of 5
Short-stay residentsrehab / post-hospital 4 of 5

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Trend — is this home getting better or worse?

Over 2025-02 to 2026-06, this home’s CMS overall rating held steady at 2 stars. From monthly CMS archive snapshots.

Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.

Overall rating2★
Inspection scorelower = better
See all quality measures vs. state & national benchmarks
MeasureThis homeState avgTypical statevs typical state
Long-stay residents whose need for help with daily activities increased15.9%19.0%15.4%typical
Long-stay residents who lose too much weight2.3%5.1%5.4%better
Long-stay residents with a catheter left in their bladder0.0%1.4%0.9%better
Long-stay residents with a urinary tract infection0.0%2.8%2.0%better
Long-stay residents with depressive symptoms0.0%4.3%6.5%check this — see note marked star below the table
Long-stay residents who were physically restrained0.0%0.3%0.1%better than state — see note marked double-dagger below the table
Long-stay residents with falls causing major injury20.3%4.5%3.3%worse
Long-stay residents on antianxiety or hypnotic medication13.3%19.3%18.9%better
Long-stay residents with pressure ulcers11.2%4.0%4.7%worse
Long-stay residents with worsening bladder/bowel control27.4%25.9%21.2%worse
Long-stay residents who got an antipsychotic medication — see the note below the table2.9%20.7%17.1%better
Short-stay residents who newly got an antipsychotic medication0.4%2.0%1.4%better
Short-stay residents given the seasonal flu vaccine92.2%75.9%79.4%better
Short-stay residents rehospitalized after admission28.1%20.7%22.6%worse
Short-stay residents with an outpatient ER visit10.2%11.4%12.0%better

* This home reported 0% on a measure where lower is better. That can mean genuinely excellent care — but because the number is self-reported, a zero can also mean the problem was not recorded. Weigh it against the inspection record above.

On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.

§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.

CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

67.8% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 652 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

67.8%U.S. median 51.5%
Got home and stayed home
10.1%U.S. median 10.7%
Went back to hospital
62.4%U.S. median 56.6%
Met the expected recovery
0.48U.S. median 0.31
Therapy hours / resident / day
0.20hours / resident / day
Physical therapy
0.23hours / resident / day
Occupational therapy
0.05hours / resident / day
Speech therapy

Met the expected recovery: 62.4% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 271 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.48 therapist hours per resident per day in 2026Q1 — more than 79% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 9% of this home’s weekday level — it runs some therapy at the weekend, at a lower level than on weekdays. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

See every short-stay measure CMS publishes for this home
MeasureThis homeU.S. medianPeriod coveredCMS’s call
Got home and stayed homeRate of successful return to home or community from a SNF67.8%CMS range 63.5–70.851.5%Oct 2022–Sep 2024better than U.S.
Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF10.1%CMS range 8.5–12.610.7%Oct 2022–Sep 2024no different from U.S.
Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge62.4%56.6%Oct 2024–Sep 2025CMS makes no comparison for this measure
Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge62.4%52.8%Oct 2024–Sep 2025CMS makes no comparison for this measure
Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge61.2%50.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified99.5%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting98.4%100.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge98.2%98.7%Oct 2024–Sep 2025CMS makes no comparison for this measure
Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay0.8%0.0%Oct 2024–Sep 2025CMS makes no comparison for this measure
New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened2.6%1.9%Oct 2024–Sep 2025CMS makes no comparison for this measure
Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization5.0%CMS range 3.5–7.07.1%Oct 2023–Sep 2024better than U.S.
Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs0.971.02Oct 2022–Sep 2024CMS makes no comparison for this measure

From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.

Staffing

0.57
RN hours/ resident / day
0.40
LPN hours/ resident / day
2.16
Aide hours/ resident / day
3.13
Total nurse hours/ resident / day
0.59
RN hoursweekends
77.2%
Total nursing turnover
45.5%
RN turnover

How full it usually is: this home is certified for 76 beds and averages 67.7 residents a day — about 89% occupied, or roughly 8 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.13 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.57 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.16 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.83 hrs/resident/day on weekends vs 3.24 on weekdays — 13% thinner on weekends. RN hours go from 0.57 to 0.59 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 77% is well above the national median of 45%. 1 administrator has left in the past year.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

6
deficiencies at the latest standard inspection (2026-02-24)
8
at the previous standard inspection (2024-09-12)

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

ABCDEFGHIJKL

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

26 citations, most serious first. The 10 most serious are shown; the remaining 16 are one tap away and print in full.

  • Potential for harm · F2026-02-24 · tag F0801 — widespread
    Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on interview and record review, the facility failed to ensure a qualified person was the director of food and nutrition services. This has the potential to affect all 55 residents of the facility. Findings are: A review of certificate dated 11/22/10 submitted on 2/26/26 revealed the Dietary Director had completed an Associate degree in Applied Science General Education. The certificate did not provide any evidence that the Dietary Director had completed the course work for the Dietary Manager certification. In an interview on 2/24/26 at 2:01 PM, the Administrator reported the Dietary Director had completed course work for the Certified Dietary Manager program. According to the Administrator, the Dietary Director could not locate the documentation at the time but the certificate would be submitted to the survey agency.The facility was unable to provide evidence the Dietary Director qualification prior exit on 2224-2026. In a follow up interview on 3-3-2026 at 9:52 AM with Administrator. the Administrator confirmed no additional documentation of the Dietary Director…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2026-02-24 · tag F0812 — failed to store, cook, and serve food safely — widespread
    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Licensure reference: 175 NAC 12-006.11(E) Based on observation and interview, the facility failed to ensure foods were stored in a manner to protect from potential cross contamination, failed to ensure kitchen equipment was maintained in a clean manner, and failed to ensure dietary staff member wore beard restraint. The has the potential to affect all 64 residents of the facility. Findings are: A.Observations on 2/18/26 between 7:21-7:54 AM revealed raw chicken and a precooked chicken patty product being thawed in the same pan on the lower rack in the walk-in refrigerator. In an interview on 2/18/26 at 8:17 AM, the Dietary Director confirmed that raw chicken should not be thawed together with a precooked chicken product. A review of 2022 United States Food and Drug Food Code revealed the following:-Food shall be protected from cross contamination by separating raw animal foods during storage, preparation, holding and display from cooked ready-to-eat food. B.Observations on 2/23/26 at 10:33 AM revealed unwrapped hot dogs lying in the bottom of an unclean food preparation sink in the…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Ecited before2026-02-24 · tag F0584 — failed to keep a safe, clean, comfortable home — pattern
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure reference: 175 NAC 12-006.19 Based on observation and interview, the facility failed to ensure common areas, dining room, and 8 [103, 117, 118, 119, 130, 162, 168, and 176] of 64 occupied rooms were maintained in a clean and sanitary manner. The facility had a total census of 64 residents. Findings are:A. Observation of Resident room [ROOM NUMBER] on 02/18/2026 at 2:32 PM revealed the floor appeared shiny directly under the bed and appeared as though a liquid was spilled and dried. B. Observation of resident room [ROOM NUMBER] on 02/18/2026 at 3:18 PM revealed dried bowel movement on the toilet riser. C. Observation of Resident room [ROOM NUMBER] on 02/18/2026 12:28 PM revealed the toilet is soiled with brown splatters and trash is full with a brief. D. Observation of Resident room [ROOM NUMBER] on 02/18/2026 at 2:22 PM revealed the toilet has a riser that has a brown substance on the seat, toilet paper on the seat, toilet paper on the floor and brown substance on the floor in front of the toilet.…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-24 · tag F0609 — failed to report abuse allegations — isolated
    Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Licensure Reference Number 175 NAC 12-006.02(H)Based on interviews and record review the facility failed to report to the State Agency an allegation of potential physical abuse for 1 (Resident 4) of 2 sampled resident. The facility census was 64. Findings are:A record review of the facility's Reporting Allegation of Abuse/Neglect/Exploitation dated 2/9/2018 revealed the following:The Licensed Nurse or Designee will: a. Remove the accused team member, guest, visitor from the area immediately. b. Notify the director of clinical services, Administrator & Director of Transitions. c. Notify the attending physician, guest family/legal representative, and medical director. d. Monitor and Document the guest's condition, including response to medical treatment or nursing interventions. e. Document actions taken in the electronic health record. A record review of Resident 4's Comprehensive Minimum Data Set (MDS, a federally mandated comprehensive assessment tool used to determine a resident's functional capabilities and helps nursing homes identify health problems) dated 1/16/2026 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.

    Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2026-02-24 · tag F0628 — isolated
    Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to notify the resident or resident representative in writing at the time of transfer the reason for hospital transfer for 1 (Resident 89) of 2 sampled residents. The facility staff identified a census of 64.Findings are:Record review of Resident 89's admission Record (AR) showed the facility admitted the resident on 11/19/2025. Further review of the AR revealed Resident 89 had diagnoses that included displaced fracture of right tibia, fracture with routine healing, and hypertension.Record review of Resident 89's Progress Notes revealed the resident was transferred to the hospital for low blood pressure.Record review of Resident 89's Electronic Health Record (EHR) including progress notes, scanned documents, and assessments revealed no evidence that the resident or resident representative was notified in writing in a manner understood by the resident or resident representative at the time of hospital transfer.During an interview on 02/23/2026 at 12:15 PM, the Director of Nursing confirmed there was no evidence the reason for…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2026-02-24 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(J)(i)(1)Based on record review, observation, and interview, the facility failed to implement interventions to prevent weight loss for 1 (Resident 99) of 4 sampled residents. The facility staff identified a census of 64.Findings are:Record review of facility policy entitled Weight Monitoring Policy dated 01/01/2023 revealed resident weights should be obtained daily for three days on admission, then weekly for four weeks, then at least monthly or as ordered by the provider, and per the direction of the Culinary Coordinator or Dietician. Further review of the policy revealed a re-weigh would be obtained if a significant weight change was noted and the Culinary Director or Dietician should be consulted to assist with interventions with the interventions recorded in the medical recorded.Record review of Resident 99's admission Record (AR) revealed the facility admitted the resident on 02/09/2026. Further review of the AR showed the resident had diagnoses that included…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · F2024-09-12 · tag F0804 — failed to serve food at safe, palatable temperature — widespread
    Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
    What the surveyor found here — an excerpt from the official record, may be distressing

    License Reference Number 175 NAC 12-006.09(J) Based on observation, record review and interview, the facility failed to ensure that food was prepared according to the recipe in order to retain nutritional value. This had the potential to affect all residents that ate foods prepared in the facility kitchen. The facility had a census of 60. Findings are: An observation on 09/11/2024 at 10:45 AM of Chef A preparing Salisbury steak patties for lunch on 09/12/24. revealed Chef A washed their hands and donned gloves. Chef A put unmeasured amounts of beef base, tomato ketchup, Worcestershire sauce, garlic, liquid eggs, mustard, breadcrumbs, onion powder, chopped onions, bell peppers and ground beef into a large pan. Chef A mixed the ingredients together while wearing gloves and then patted out unmeasured amounts of beef into patties. Chef A did not weigh the patties to ensure they met the required ounces identified in the recipe. An interview on 09/11/2024 at 10:55 AM with Chef A confirmed they did not measure ingredients or follow the recipe as it was written. A record review of the…

    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.

    Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2024-09-12 · tag F0725 — failed to have enough nursing staff — pattern
    Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12.006.04 Based on observation, interview and record review the facility failed to ensure that call lights were answered in a timely manner for 10 of 28 (Resident 103, 33, 58,56, 61, 44, 70, 156, 13 and 253) sampled residents. The facility census was 60. The Findings are: A. Record review of Resident 61's Electronic Health Record (EHR, is a digital version of a patient's paper chart) revealed a nursing admission screening/history document dated 09-03-2024 which indicated Resident 61 had diagnosis of Diabetes Mellitus and anemia, required staff assistance with bed mobility and was dependent on staff for transfers. Record review of a Brief Interview of Mental Status (BIMS, an assessment that aids in detecting cognitive impairment. A score of 0-7 equals severe impairment, 8-12 indicates moderate impairment and 13-15 indicates cognitively intact) dated 09-05-2024 for Resident 61 revealed a score of 14 indicating cognitively intact. An interview with Resident 61 on 09-09-2024 at…

    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.

    Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-12 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12.006.04(F)(i)(5) Based on interview and record review the facility failed to notify the physician and obtain treatment orders for a pressure ulcer for 1 (Resident 61) of 1 resident sampled. The facility census was 60. The findings are: Record review of Resident 61's Electronic Health Record (EHR, is a digital version of a patient's paper chart) revealed a nursing admission screening/history document dated 09-03-2024 revealed an admission date of 09-03-2024 and Resident 61 had diagnosis of Diabetes Mellitus and anemia, required staff assistance with bed mobility and was dependent on staff for transfers. The document also revealed Resident 61 had a history of pressure ulcers. Record review of a Brief Interview of Mental Status (BIMS, an assessment that aids in detecting cognitive impairment. A score of 0-7 equals severe impairment, 8-12 indicates moderate impairment and 13-15 indicates cognitively intact) dated 09-05-2024 revealed a score of 14 indicating cognitively intact. 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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-12 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
    Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.19 and 12.006.19(B) Based on observation and interviews, the facility failed to maintain cleanliness of floors, toilets, equipment, and upkeep of the floors and walls in 4 resident rooms ( 157, 153, 104, and 142). The facility identified a census of 60. Findings are: Observations in room [ROOM NUMBER] on 9/9/24 at 11:28 AM and 9/10/24 at 1:40 PM revealed scratches where paint and dry wall had worn away on the bathroom door frame. Observations in room [ROOM NUMBER] on 9/9/24 at 11:28 AM and 9/10/24 at 1:25 PM revealed a carpet stain right inside the resident's room. Observations in room [ROOM NUMBER] on 9/9/24 at 1:45 PM and 9/10/24 at 1:30 PM revealed a toilet riser over the toilet with the foot pegs of the toilet riser sunken in the floor with the cement around the foot pegs worn away. The floor around the toilet was also stained. Observations in room [ROOM NUMBER] on 9/9/24 at 12:13 PM and 9/10/24 at 12:03 PM revealed a urinary catheter bag stained with blood in the…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
Show the remaining 16 citations
  • Potential for harm · D2024-09-12 · tag F0655 — isolated
    Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(F)(i) Based on record review and interview, the facility failed to ensure that the baseline care plan (BCP, a written plan required to be developed within 48 hours of admission detailing the instructions needed to provide initial effective and person-centered quality care for a resident) included significant medical information needed to provide care was completed for 2 (Residents 58 and 73) of 15 sampled residents reviewed for baseline care plans. The facility census was 60. Findings are: A. Record review of Resident 58's admission Face Sheet revealed an admission date of 9/5/24. Diagnoses included: Diabetes Mellitus Type 2 (DM insulin dependent) and Hypertension (HTN, high blood pressure), Atrial Fibrillation and Major Depressive Disorder Record review of Resident 58's admission Physician Orders dated 9/5/24 revealed the following orders for monitoring: - Antidepressant behavior monitoring for signs / symptoms of target behaviors. Notify physician of increased…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-12 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
    Provide appropriate pressure ulcer care and prevent new ulcers from developing.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12.006.09(H)(iii)(1) Based on observation, interview and record review the facility failed to identify, evaluate and provide treatment for a pressure ulcer for 2 (Resident 61 and 155) of 3 sampled residents. The facility census was 60. Findings are: A. Record review of Resident 155's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) dated 06-07-2024 revealed the facility staff assessed the following about the resident: - Brief Interview of Mental Status (BIMS, an assessment that aids in detecting cognitive impairment. A score of 0-7 equals severe impairment, 8-12 indicates moderate impairment and 13-15 indicates cognitively intact) score of 15 indicating cognitively intact. -Required moderate assistance with bed mobility, transfers and lower body dressing. -Required maximal assistance with bathing. -Currently had a pressure ulcer. Record review of Resident 155's Electronic Health Record ((EHR, is a digital version of a patient's paper chart))…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-09-12 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 12.006.09(1) Based on observation, interview and record review the facility failed to investigate and identify causal factors for injuries for 1 (Resident 56) of 5 sampled residents. The facility census was 60. Findings are: Record review of Resident 56's Minimum Data Set (MDS, a federally mandated assessment tool used for care planning) revealed an admission date of 08-27-2024 with diagnosis of Chronic Obstructive Pulmonary Disease (COPD), Respiratory Failure, Right Below the Knee Amputation (BKA) and anxiety. The MDS indicated Resident 56 required supervision with transfers, upper body dressing and hygiene and required moderate assistance with bathing and lower body dressing. An observation on 09-09-2024 at 9:23 AM revealed a foam island dressing to Resident 56's right elbow with the date 09-09-2024 written on the dressing. An interview on 09-09-2024 at 9:30 AM with Resident 56 revealed (gender) had bumped the right elbow on the handrail next to the toilet sometime last week. Record…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-09-12 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09(H) Based on record review and interview, the facility failed to identify and monitor specific target behaviors for the use of an antidepressant [a class of medications used to treat depression] medication for 2 (Residents 58 and 73) of 5 residents reviewed for psychotropic [a group of medications used to treat mental health disorders] medication use. The facility census was 60. Findings are: A. Record review of a facility policy entitled Psychotropic Medication dated 1/1/23 identified the following: - A psychotropic drug is any drug that affects the brains activities associated with mental processes or behavior. Psychotropic drugs include Antidepressants. - Use of psychotropic medications in specific circumstances: b. Enduring conditions ( non-acute, chronic, prolonged): The patients symptoms and therapeutic goals shall be specifically identified and documented. B. Record review of Resident 58's admission Face Sheet revealed that Resident 58 was admitted to the…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2024-04-18 · tag F0580 — failed to tell family and doctor about changes — isolated
    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure reference: 175 NAC 12-006.04C3a(6) Based on record review and interview, the facility failed to ensure the medical provider was notified of blood sugar levels outside of parameters for 1 [Resident 4] of 4 sampled residents. The facility had a total census of 72 residents. Findings are: A review of admission Record revealed Resident 4 was admitted to the facility on [DATE] with a readmission date of 3/6/24 with a primary diagnoses of end stage renal disease, dependence on renal dialysis, and a type 2 diabetes mellitus without complications. A review of Resident 4's 4/2024 MAR [Medication Administration Record] revealed an order for blood glucose monitoring 4 times per day with the physician to be notified of blood sugars of less than 70 or greater than 400. A review of Resident 4 Progress Notes dated 4/8/24 at 4:39 PM revealed Resident 4's Aspart insulin [rapid acting insulin] was held due a blood sugar of 67 with a snack given. Progress note did not reveal that Resident 4's medical provider was…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-18 · tag F0698 — failed to provide proper dialysis care — isolated
    Provide safe, appropriate dialysis care/services for a resident who requires such services.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12-006.09 Based on observation, interview, and record review, the facility failed to ensure coordination of medication administration with dialysis schedule for 2 [Residents 2 and 4] of 2 sampled residents requiring dialysis. The facility had a total census of 72 residents. Findings are: A. A review of a admission Record revealed Resident 2 was admitted to the facility on [DATE] with a readmission date of 4/15/24. The admission Record for Resident 2 listed a primary diagnosis of pneumonia [an infection in the lungs] and diagnoses of type 2 diabetes mellitus [a disorder in which the body has trouble controlling blood sugar] without complications and end stage renal disease [a condition in which the kidneys lose the ability to remove waste and balance fluids]. A review of Resident 2's 4/2024 MAR [Medication Administration Record] revealed Resident 2 had an appointment for dialysis at 6:15 AM every Tuesday, Thursday, and Saturday with Resident 2 to arrive at the dialysis facility…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-04-18 · tag F0761 — failed to label and store drugs safely — isolated
    Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Licensure reference: 175 NAC 12-006.12E1 Based on observations, interview, and record review, the facility failed to ensure insulin pens were labeled with date opened for 3 [Residents 2, 3, and 4] of 4 sampled residents with orders for insulin. The facility had a total census of 72 residents. Findings are: A. Observations on 4/18/24 at 12:15 PM revealed Resident 2's Aspart [rapid acting insulin] and Glargine [long-acting insulin] insulin pens were not dated with date opened. LPN A obtained a new Aspart insulin pen from the facility emergency medication stock for administration of insulin to Resident 2. In an interview on 4/18/24 at 12:15 PM, LPN A indicated both insulin pens would be disposed of due to not being dated when opened. A review of Resident 2's 4/2024 MAR [Medication Administration Record] revealed insulin pen is to be discarded 28 days after initial use. B. Observations on 4/18/24 at 7:19 AM revealed Resident 3's Glargine insulin pen was not labeled with date opened. LPN A obtained a new Glargine insulin pen from the facility emergency medication stock for administration…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-29 · tag F0684 — failed to provide proper treatment and quality of care — isolated
    Provide appropriate treatment and care according to orders, resident’s preferences and goals.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number : 175 NAC 12-006.09 Based on record review and interview, the facility staff failed to ensure neurological assessments were completed after a fall to evaluate for potential changes in condition for 2 [Residents 5 and 3] of 4 sampled residents with falls. The facility had a total census of 59 residents. Findings are: A. A review of facility policy titled Neuro Checks dated 3/31/2021 revealed the following policy: A Neuro check is a simple and standardized assessment to detect changes in level of consciousness. These may be performed on an individual with a post-fall head injury, or unwitnessed fall. Consciousness is the most sensitive indicator of neurological change. Procedure is as follows: 1. Neuro checks will be completed per physician order or initiated by the nurse, at their discretion, based on physical assessment of the resident, guest, or elder. 2. Neuro checks will be completed on the resident, guest, or elder with an unwitnessed fall or fall with head injury. 3. The nurse…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2024-02-29 · tag F0760 — failed to prevent significant medication errors — isolated
    Ensure that residents are free from significant medication errors.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure reference: 175 NAC 12-006.09D. Based on record review and interview, the facility failed to ensure 1 [Resident 2] of 7 sampled residents was free from a significant medication error. The facility had a total census of 59 residents. Findings are: A review of admission Record revealed Resident 2 was admitted to the facility on [DATE] with a diagnosis of type 2 Diabetes Mellitus without complications. A review of Resident 2's 2/2024 MAR [Medication Administration Record] revealed the following orders for insulin: -Insulin Glargine Solution [long acting insulin], inject 15 units subcutaneously in the morning -Insulin aspart [short acting insulin], inject 3 unit subcutaneously 3 times a day at AM, noon, and PM -Insulin Aspart Subcutaneous, inject per sliding scale: blood sugar 0-199=0 units; 200-250=2 units; 251-299=3 units; 300-350=4 units; 351-400=5 units; 401-450=8 units; 451+, =10 units, subcutaneously 3 times per day A review of Resident 2's Febuary 2024 MAR revealed Insulin Aspart 3 units scheduled…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-08-03 · tag F0638 — pattern
    Assure that each resident’s assessment is updated at least once every 3 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175NAC 12-006.09B Based on record review and interview, the facility failed to complete a quarterly Minimum Data Set (MDS- a mandatory comprehensive assessment tool used for care planning) within the regulatory time frame for 5 (Residents 19, 30, 38, 43, and 55) of 6 residents reviewed. The facility census was 70. Findings are: Record review of the Centers for Medicare and Medicaid Services (CMS) RAI manual version v1.17.1 dated October 2019 revealed that a Quarterly MDS is used to track the resident's status between comprehensive assessments, and to ensure monitoring of critical indicators of the gradual onset of significant changes in resident status. The MDS completion date must be no later than 14 days after the Assessment Reference Date (ARD). A. Review of the admission Record for Resident 19 revealed that Resident 19 admitted to the facility on [DATE]. Review of the electronic health record (EHR) for Resident 19 revealed that a quarterly MDS was set with an ARD of 6/20/23. The…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · E2023-08-03 · tag F0640 — pattern
    Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
    What the surveyor found here — an excerpt from the official record, may be distressing

    Based on record review and interview, the facility failed to transmit a Minimum Data Set (MDS- a mandatory comprehensive assessment tool used for care planning) assessment within the regulatory time frame for 5 (Residents 19, 30, 38, 43, and 55) of 6 residents reviewed. The facility census was 70. Findings are: Record review of the Centers for Medicare and Medicaid Services (CMS) RAI manual version v1.17.1 dated October 2019 revealed that a facility must transmit required MDS9Minimum Data Set, a federally mandated assessment tool used for care planning) data records to CMS' Quality Improvement and Evaluation System Assessment Submission and Processing system and that the MDS must be transmitted by the 14th day of completion. A. Review of the electronic health record (EHR) for Resident 19 revealed that a quarterly MDS was set with an ARD of 6/20/23. The status of the MDS was documented as completed on 7/17/23 and had not been transmitted as of 8/1/23. B. Review of the EHR for Resident 30 revealed that a quarterly MDS was set with an ARD of 6/9/23. The status of the MDS was documented…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-03 · tag F0550 — failed to protect resident dignity and rights — isolated
    Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175 NAC 12.006.05(21) Based on observation, interview, and record review, the facility failed to ensure the Foley Catheter Bag (a bag that holds urine) was covered to protect the dignity of 2 (Residents 54 and 26) of 3 sampled residents. The facility census was 70. Findings are: A record review of the undated Foley Catheter Bag Policy revealed a resident's Foley catheter bag should be covered, or placed out of sight on the resident's bed. A. A record review of Resident 54's Minimum Data Set (MDS)(an assessment tool that measures the health status of nursing home residents) list dated 08/02/2023 revealed Resident 54 was admitted to the facility on [DATE]. A record review of Resident 54's Diagnoses/Surgical Procs (Procedures) dated 08/02/2023 revealed Resident 54 had diagnoses of Benign Prostatic Hyperplasia (enlarged prostate), Bladder-Neck Obstruction (obstruction of urinary flow at the bladder neck), and Retention of Urine among others. A record review of Resident 54's MDS dated…

    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.

    Resident Rights Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-03 · tag F0636 — isolated
    Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175NAC 12-006.09B1(2) Based on record review and interview, the facility failed to ensure that the resident significant change in status assessment was completed within the regulatory time frame for 1 (Resident 26) of 6 resident reviewed. The facility census was 70. Findings are: Record review of the Centers for Medicare and Medicaid Services (CMS) RAI manual version v1.17.1 dated October 2019 revealed that a Significant Change in Status Assessment (SCSA) is a comprehensive assessment for a resident that must be completed when the facility team has determined that a resident meets the significant change guidelines for either major improvement or decline. The Minimum Data Set (MDS-a mandatory comprehensive assessment tool used for care planning) completion date must be no later than 14 days after the determination that the criteria for an SCSA were met. Record review of the admission Record for Resident 26 revealed Resident 26 admitted to the facility on [DATE]. Record review of the…

    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.

    Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-03 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
    Provide enough food/fluids to maintain a resident's health.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY LICENSURE REFERENCE NUMBER 175 NAC 12-006.09D8b1 Based on interview, record review and observation, the facility staff failed to identify and implement interventions for a significant weight loss for 1 (Resident 39) of 8 sampled residents. The facility identified a census of 70. The findings are: Record review of Resident 39's Care Plan dated 6-29-2023 revealed a goal for Resident 39 was to maintain nutrition status through weight maintenance, diet tolerance. Interventions are to assist with ordering meals, set up, and assist with eating meals. Record review of Resident 39's Nurse tech Care Plan (A Way of communicating with the nurse aides to care for each resident) on 8/2/23 revealed that Resident 39 Needs to be checked frequently, meals ordered, and set up/assist resident with the meal. Record review of the Registered Dietician's (RD) evaluation of Resident 39's nutritional requirements dated 7-08-2023 revealed the RD identified Resident 39 admitted to the facility on [DATE] with a weight of 145 pounds.…

    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.

    Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · D2023-08-03 · tag F0757 — failed to avoid unnecessary drugs — isolated
    Ensure each resident’s drug regimen must be free from unnecessary drugs.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Licensure Reference Number 175NAC 12-006.09D Based on record review and interviews, the facility failed to ensure non-pharmacological interventions were attempted prior to administration of an as needed (PRN) pain medication for 1( Resident 172) of 5 sampled residents. The facility census was 70 Findings are: Review of the admission record for Resident 172 revealed that Resident 172 admitted to the facility on [DATE] with a diagnosis of encounter for other orthopedic aftercare and spinal stenosis, lumbar region without neurogenic claudication. In an interview on 7/31/23 at 9:16 AM Resident 172 reported that Resident 172 was admitted to the facility after back surgery. Resident 172 revealed Resident 172 had frequent pain to her back. Review of Resident 172's physician orders, dated 8/1/23, revealed an order for: -Hydroco/APAP (medication to treat pain) tablet (tab) 5-325 milligram (mg) 1 tab by mouth every 6 hours as needed for pain -Ice to the affected area as needed Review of Resident 172's electronic…

    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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction
  • Potential for harm · Dcited before2023-08-03 · tag F0758 — failed to limit and justify psychotropic drugs — isolated
    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
    What the surveyor found here — an excerpt from the official record, may be distressing

    NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure target behavior monitoring and side effect monitoring were completed for Resident 158's Generalized Anxiety Disorder and Resident 172's Depressive Disorder. This affected 2 of 5 sampled residents. The facility census was 70. Findings are: A. A record review of the undated Behavior Monitoring Policy revealed that the occurrence of adverse behaviors should be documented on the Behavior Assessment in the Electronic Health Record (EHR) and in nurse's notes. A record review of the Medication Regimen Review Policy dated 01/01/2023 revealed the facility's nurse should have followed up on the pharmacist's recommendations to ensure recommendations were completed. The facility's nurse should have reviewed and followed up on recommendations made by the Pharmacist. A record review of Resident 158's Clinical Note Entry dated 07/18/2023 revealed Resident 158 was admitted to the facility on [DATE]. A record review of Resident 158's History and Physical (H&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.

    Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Worried about a resident here? There are three different people you can turn to, and they do different jobs:
  • Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
  • Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
  • State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Not sure where to start, or need other help? Dial 2-1-1 for local resources — and if a call is hard or impossible for you, many local 211s also take a text (send your ZIP code to 898-211) or a web chat at 211.org; both vary by area, and 211.org will show what yours offers. Deaf or hard of hearing: dial 711 for the telecommunications relay service, then any number above. In an emergency, call 911.
It is illegal for a facility to retaliate against a resident or family for reporting a concern: federal law gives a resident the right to voice grievances — to the home or to any outside agency — without discrimination or reprisal (42 CFR §483.10(j)(1)). You may report anonymously.

Fines & penalties

No federal fines in the current CMS record.

Who owns this facility

Owner / managerTypeRoleShareSince
HILLCREST OPERATING VENTURES, LLCOrganization5% OR GREATER DIRECT OWNERSHIP INTEREST100%since 05/06/2016
KENDALL, AMBERIndividualW-2 MANAGING EMPLOYEEsince 01/01/2024
JANICKI, JAMESIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2024
MULHEARN, KEVINIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2024
OESTMANN, MATTHEWIndividualCORPORATE OFFICER; OPERATIONAL/MANAGERIAL CONTROLsince 01/01/2024
HILLCREST HEALTH SYSTEMS INCOrganizationOPERATIONAL/MANAGERIAL CONTROLsince 06/01/2017
ASWEGE-MEZENBERG, DEBRAIndividualOPERATIONAL/MANAGERIAL CONTROLsince 07/01/2023

CMS files one row per role, so the 10 rows in the source record cover these 7 parties — each is shown once here with every role it holds. Nothing is omitted.

2 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

$12.7M
Net patient revenuemost recent cost report
+2.5%
Operating marginrevenue minus expenses
$3.3M
Related-party expense27% of expenses
Who pays — share of resident-days
Medicaid 19%Medicare 47%Other / private 34%

This home reported $3.3M paid to related parties — landlords or management companies under common ownership — equal to about 27% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

$481per resident / day
operating cost
$14,612per month
≈ monthly operating cost
$493per day
avg. revenue, all payers

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in NE

Paying with Medicaid

This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the Nebraska Medicaid page.

Typical monthly cost in Nebraska
$8,377/mo
Nursing home (semi-private)
$9,216/mo
Nursing home (private)
$6,350/mo
Assisted living

Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.

Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 285302. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2026-02-24, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →

Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →

Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.

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