Hillcrest Health & Rehab
Inspection Findings
F-Tag F0684
F 0684 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
on Resident 3. Registered Nurse C entered the room and discovered that Resident 3 was gone. A review of Resident 3's Progress Note dated 8/31/25 at 3:49 PM revealed that Registered Nurse C was notified at 9:30 AM that Resident 3 was not responding. Resident 3 was checked on and no signs of life were noted including no heartbeat or respirations. In interviews on 9/3/25 at 4:07 PM, 4:48 PM, and 5:23 PM, the Director of Nursing reported the expectations:-Resident 3's doctor/provider would have been notified when oxygen was applied to Resident 3-When Resident 3's oxygen saturation was low the physician orders would have been checked for any orders for oxygen or as needed medication orders-Resident 3 would have been checked to ensure Resident 3 was breathing through the nose as oxygen was coming through nasal cannula-Resident 3's oxygen saturation level would be rechecked and if oxygen saturation level did not improve doctor would have been called A review of undated facility policy titled Change In Condition or Status of Guest revealed the following:- 3. Prior to notifying the Physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the SBAR (Interact Version 4.0) Communication Form. B. In interviews
on 9/3/25 at 7:47 AM, 10:12 AM, and 10:30 AM, the Administrator reported that an investigation was started on 8/31/25 after Administrator was notified of Resident 3's death with involved staff members being suspended. The Administrator reported that education was of all nursing staff members with all nursing staff members required to complete the education before the next scheduled shift. An audit of all residents with oxygen was completed to ensure oxygen orders were in place. Vital sign parameters were posted in facility clinics. A review of facility education began on 8/31/25 revealed staff members were educated about the following:-Clinical alert monitoring-Change in Condition or Status policy A review of facility competency checks revealed competency evaluations began on 8/31/25 on notification of nurses of changes of condition.
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Hillcrest Health & Rehab in Bellevue, NE inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Bellevue, NE, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Hillcrest Health & Rehab or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.