Hillcrest Health & Rehab
Hillcrest Health & Rehab in Bellevue, NE — inspection on September 3, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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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