Inspection Reports for Crest View Care Center
420 Gordon Avenue, CHADRON, NE, 69337
Back to Facility ProfileDeficiencies (last 10 years)
Deficiencies (over 10 years)
10.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
150% worse than Nebraska average
Nebraska average: 4.2 deficiencies/yearDeficiencies per year
24
18
12
6
0
Census
Latest occupancy rate
40% occupied
Based on a June 2019 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Renewal
Capacity: 70
Deficiencies: 0
Date: Feb 26, 2020
Visit Reason
The document is a Nursing Home Licensure Renewal Application and related certification and occupancy permit documents for Crest View Care Center, indicating the facility's license renewal process and compliance verification.
Findings
The documents certify that Crest View Care Center meets statutory requirements for SNF/NF dual certification and is licensed for 70 beds. The renewal application confirms facility ownership, services provided, and licensure status. The occupancy permit confirms the maximum occupancy of 70 beds as of 2019.
Report Facts
Total licensed beds: 70
License expiration date: Mar 31, 2020
Occupancy permit date issued: Sep 4, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Heather Jordan | Administrator | Named on Nursing Home Licensure Renewal Application |
| Dorene Walker | Director of Nursing | Named on Nursing Home Licensure Renewal Application |
| Mary Ellen Lantis | President | Named in ownership/control and as authorized representative on renewal application |
| Mike Moore | Treasurer and CFO | Named in ownership/control |
| Cammy Lantis | Secretary and VP Risk Management and Secretary | Named in ownership/control |
| Wendy Soulek | COO | Named in management company ownership/control |
| Leah Rinard | VP Outsourcing and HR | Named in management company ownership/control |
Inspection Report
Complaint Investigation
Census: 28
Capacity: 70
Deficiencies: 7
Date: Jun 17, 2019
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Crest View Care Center from June 17, 2019 to June 20, 2019. The investigation included review of resident records, observation of care and services, and interviews with residents, family members, and staff.
Complaint Details
The visit was complaint-related with allegations that the facility failed to ensure residents are treated with respect and dignity, failed to thoroughly investigate alleged violations, and failed to establish and/or implement policies regarding facility pets. All allegations were found to have no violations.
Findings
The complaint allegations regarding respect and dignity, investigation of violations, and pet policies were found to have no violations. However, deficiencies were identified in care plan revisions, pharmacy services, medication administration, drug storage, infection control, emergency lighting, fire safety, and electrical equipment.
Deficiencies (7)
Failed to update one resident's care plan to identify edema and initiation of diuretic medication.
Failed to ensure heart medication was administered according to physician's ordered parameters and narcotic accounting records were incomplete.
Failed to remove out of date eye drops from medication cart.
Failed to establish and maintain an effective infection prevention and control program including proper storage of CPAP mask, handling of clean clothing, and monitoring employee illnesses.
Failed to provide adequate emergency lighting in the 300 corridor.
Failed to provide one-hour fire rated separation at a hazardous area due to void space in fire separation wall between furnace room and laundry room.
Failed to adequately secure electrical power strips in employee break room and physical therapy office.
Report Facts
Facility census: 28
Total licensed capacity: 70
Sample size: 14
Deficiency completion dates: Aug 4, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Connie Vogt | Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed complaint investigation letter |
| RN-B | Registered Nurse, MDS Coordinator | Interviewed regarding care plan and medication administration deficiencies |
| LPN-A | Licensed Practical Nurse | Interviewed regarding narcotic log and medication storage |
| HSM-C | Housekeeping Staff Member | Observed handling clean clothing incorrectly |
| Maintenance Personnel 1 | Interviewed regarding emergency lighting and fire wall deficiencies | |
| Administrator 1 | Facility Administrator | Interviewed regarding multiple deficiencies including emergency lighting, fire safety, infection control, and electrical equipment |
Inspection Report
Annual Inspection
Census: 29
Capacity: 70
Deficiencies: 22
Date: Jul 24, 2018
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Crest View Healthcare Community on July 18-24, 2018, by representatives of the Department of Health and Human Services Division of Public Health.
Complaint Details
The complaint allegations were that the facility failed to complete written investigations within five working days and failed to treat residents with respect and dignity. The facility was found to be in compliance with these allegations.
Findings
The facility was found to be in compliance with complaint allegations regarding investigations and respect and dignity. However, multiple deficiencies were identified including emergency preparedness plan deficiencies, environmental safety issues, care planning and assessment inaccuracies, medication management issues, food safety violations, fire safety code violations, and staff performance review deficiencies.
Deficiencies (22)
Failed to develop a comprehensive emergency preparedness plan including all required components.
Failed to replace and repair broken tile located behind the toilet and floor in Resident 29's bathroom.
Failed to provide written notice before transfer or discharge for Residents 30 and 32 regarding hospital discharge.
Failed to notify residents 7 and 22 or their representatives of the bed hold policy within 24 hours of hospital transfer.
Failed to complete a significant change MDS assessment for Resident 6 when indicated.
Failed to accurately code MDS assessments related to bed mobility for Resident 15 and significant weight loss for Resident 32.
Failed to develop care plans for Resident 13's missing and broken teeth and Resident 14's pain issues requiring medication intervention.
Failed to update care plans to address urinary tract infection for Resident 15, electrolyte imbalance and fluid restrictions for Resident 13, urinary tract infection for Resident 30, and weight loss, fluid restriction and edema for Resident 32.
Failed to ensure indwelling urinary catheter was secured to prevent pulling and promote comfort for Resident 11.
Failed to ensure dialysis access site was assessed at least daily for Residents 15 and 32.
Failed to complete annual performance reviews for four sampled nursing assistants.
Failed to ensure drug regimen was free from unnecessary drugs; specifically, failed to ensure follow-up assessments for antibiotic effectiveness and adverse reactions for Resident 15.
Failed to label medication eye drop bottle with resident's full name and directions matching physician order for Resident 14.
Failed to maintain food temperature to prevent foodborne illness; orange and grape juice served at room temperature.
Failed to employ a qualified dietary manager with required credentials or continuing education.
Failed to provide accessibility of a fire alarm manual pull device; device obscured by storage items.
Failed to provide complete smoke detection coverage; corridor leading to shower and tub rooms open to egress corridor without smoke detection.
Failed to maintain required separation distance between storage and fire sprinklers in two locations.
Failed to prohibit use of electrical extension cords in resident rooms; extension cord observed in resident room 307.
Failed to ensure oxygen tanks were stored and transported in a manner to prevent tipping or breaking; unsecured oxygen tanks observed in Resident 32's room and nurse's station.
Failed to ensure bathroom ventilation systems were functioning preventing lingering odors for Residents 14, 16, and 29.
Failed to ensure proper hand hygiene and cleaning of kitchen equipment; dust and debris on oven and staff not washing hands properly.
Report Facts
Facility census: 29
Total licensed capacity: 70
Number of residents receiving oxygen: 10
Number of sampled residents: 16
Number of sampled nursing assistants: 4
Number of residents on dialysis: 2
Temperature of orange juice: 45
Temperature of grape juice: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator, Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed complaint investigation letter |
| Cathy Snyder | Administrator | Facility administrator during inspection |
| Maintenance Supervisor | Identified broken tile and non-functional bathroom ventilation; verified fire alarm and sprinkler deficiencies | |
| Administrator | Verified multiple deficiencies including fire alarm, sprinkler, ventilation, and care plan issues | |
| RN-H | MDS Coordinator | Interviewed regarding MDS assessment and care plan deficiencies |
| RN-J | Registered Nurse | Interviewed regarding medication administration and care plan deficiencies |
| NA-G | Nursing Assistant | Observed catheter care without catheter secure device |
| Dietary Manager | Interviewed regarding food safety and qualifications | |
| Health Services Group Consultant | Interviewed regarding food safety | |
| Social Services Director | Interviewed regarding transfer/discharge notices and care plan addendum |
Inspection Report
Routine
Census: 34
Deficiencies: 15
Date: Jun 14, 2017
Visit Reason
Routine state inspection survey conducted to assess compliance with regulatory requirements for skilled nursing facilities.
Findings
The facility was found deficient in multiple areas including failure to remove transfer belts after use, incomplete care plans, inadequate pain management during wound care, improper catheter bag placement, oxygen administration and concentrator placement issues, food service sanitation problems, medication labeling discrepancies, ventilation and fire safety code violations including sprinkler maintenance and smoke barrier integrity.
Deficiencies (15)
Failed to remove transfer belt after use to promote dignity for one resident.
Failed to develop comprehensive care plans addressing anticoagulant use and range of motion limitations.
Failed to update care plan to reflect resident's sleeping arrangements and preferences.
Failed to ensure resident participation in care planning process and update care plans accordingly.
Failed to administer pain medication to promote comfort during wound care.
Failed to keep urinary catheter drainage bag off the floor to reduce risk of urinary tract infections.
Failed to ensure oxygen was administered as ordered and oxygen concentrator was positioned for efficient operation.
Failed to ensure medication label instructions matched current physician orders for aerosol inhalation treatment.
Failed to maintain kitchen sanitation including cracked ceiling, rusty vent, dirty sprinkler heads, and missing freezer temperature logs.
Failed to maintain fire sprinkler system by allowing grease and lint accumulation on sprinkler heads and not having required spare sprinkler heads.
Failed to maintain smoke/fire barrier walls in attic allowing potential smoke and fire spread.
Used corridors as return air plenums for HVAC system, compromising protected egress corridors.
Failed to separate full and empty oxygen cylinders in storage room, risking delay in emergency supply.
Failed to ensure bathroom exhaust fans provided adequate ventilation and odor control in resident bathrooms.
Dietary Manager did not meet minimum state licensure qualifications for Food Service Director.
Report Facts
Facility census: 34
Sampled residents: 30
Sampled residents: 12
Deficiency counts: 6
Deficiency counts: 5
Deficiency counts: 2
Deficiency counts: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Don Fritz | Assistant State Fire Marshal | Provided correspondence and recommendations related to fire safety and waiver requests. |
| Administrator A | Interviewed and verified multiple findings related to fire safety, ventilation, and care plan deficiencies. | |
| LPN - A | Licensed Practical Nurse | Observed administering wound care and aerosol medication; interviewed regarding medication administration. |
| Director of Nursing | Interviewed regarding care plan deficiencies, pain management, catheter placement, oxygen administration, and medication labeling. | |
| Social Services Director | Interviewed regarding resident sleeping arrangements and catheter bag placement. | |
| Dietary Manager | Interviewed regarding kitchen sanitation deficiencies and licensure qualifications. | |
| Maintenance Supervisor | Interviewed regarding ventilation and fire safety deficiencies. |
Inspection Report
Renewal
Capacity: 70
Deficiencies: 0
Date: Feb 17, 2017
Visit Reason
This document is a nursing home licensure renewal application and related certification for Crest View Healthcare Community, verifying the facility's license renewal and compliance with statutory requirements.
Findings
The document confirms that Crest View Healthcare Community is licensed as a Skilled Nursing Facility/Nursing Facility dual certification with a licensed capacity of 70 beds. It includes ownership disclosure, certification of compliance with state regulations, and an occupancy permit issued by the Nebraska State Fire Marshal.
Report Facts
Number of beds to be relicensed: 70
Renewal application received date: Feb 17, 2017
Occupancy permit date issued: Jun 28, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cathy Snyder | Administrator | Named as facility administrator on renewal application |
| Anna Stetsen | Director of Nursing | Named as Director of Nursing on renewal application |
| Thomas E. Boerboom | Listed as Director and 50% owner of LE Holding LLC, related to facility ownership | |
| Paul J. Contris | Listed as Director and 50% owner of LE Holding LLC, related to facility ownership | |
| Pat Gould | Deputy State Fire Marshal | Inspected the facility and issued the occupancy permit |
Inspection Report
Annual Inspection
Census: 25
Deficiencies: 5
Date: Jun 30, 2016
Visit Reason
The inspection was conducted as a regulatory annual survey to assess compliance with licensure regulations and the Life Safety Code for Crest View Healthcare Community.
Findings
The facility was found deficient in multiple areas including failure to develop comprehensive care plans for bruising, inadequate monitoring of facial bruising, failure to monitor symptoms of depression for a resident on antidepressants, improper labeling of insulin containers, and unsafe HVAC system design affecting fire safety.
Deficiencies (5)
Failed to develop a care plan to address care related to bruising for one resident.
Failed to assess and monitor facial bruising to ensure healing without complications for one resident.
Failed to monitor symptoms of depression for one resident on antidepressant medication to ensure therapeutic benefits.
Failed to ensure insulin containers were labeled to reflect physician's orders for two residents.
Failed to provide protected egress corridors by using corridors as return air plenums, risking smoke and fire spread.
Report Facts
Facility census: 25
Deficiency completion dates: Jul 24, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed confirming deficiencies related to care plans and monitoring | |
| RN - A | Registered Nurse | Observed medication administration and insulin labeling deficiencies |
| Maintenance Staff A | Confirmed HVAC system deficiencies related to fire safety | |
| Administrator | Verified insulin labeling deficiencies |
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 0
Date: Mar 2, 2016
Visit Reason
An unannounced visit was conducted to investigate a complaint that the facility fails to provide meals as ordered by physician.
Complaint Details
The complaint alleged failure to provide meals as ordered by physician. The allegation was investigated and found to have no deficiency.
Findings
The investigation included observations, interviews, and record reviews of sampled residents. No deficiency was cited for the allegation that the facility failed to provide meals as ordered by physician.
Report Facts
Sampled residents observed and interviewed: 4
Facility census: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Eve Lewis | Program Manager | Signed the report as Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 2
Date: Jul 20, 2015
Visit Reason
An unannounced visit was conducted to investigate complaints regarding failure to protect residents from injury and failure to ensure residents are free from misappropriation at Crest View Healthcare Community.
Complaint Details
The complaint investigation was substantiated with violations cited at Federal Licensure Tags F-314 and F-224, and corresponding State Licensure Tags. The allegations included failure to protect residents from injury and failure to ensure residents are free from misappropriation. The facility census was 33 at the time of investigation.
Findings
The investigation substantiated two violations: failure to protect a resident from injury related to pressure ulcer development, and failure to protect a resident from misappropriation of money. Observations, interviews, and record reviews confirmed these deficiencies, including a resident developing a pressure ulcer after being left on a bedpan and a resident's money being missing due to lack of secure storage.
Deficiencies (2)
Failure to protect a resident from injury related to pressure ulcer development due to being left on a bedpan overnight.
Failure to ensure residents are free from misappropriation of money due to lack of secure storage and missing funds.
Report Facts
Facility census: 33
Missing money amount: 185
Braden Score: 14
Date of incident: Jul 9, 2015
Date of survey: Jul 20, 2015
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | RN, Training Coordinator - Office of LTC Facilities - Licensure Unit - Division of Public Health | Signed the complaint investigation letter. |
| Kathy Gibbons | Social Worker | Investigator conducting the complaint investigation. |
| Keeli Klein | Registered Nurse | Investigator conducting the complaint investigation. |
| Cathy Snyder | Administrator | Facility administrator interviewed during investigation and involved in findings. |
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 0
Date: Jul 1, 2015
Visit Reason
An unannounced visit was conducted to investigate a complaint regarding the facility's failure to change fall interventions after residents were identified at risk for falls.
Complaint Details
The complaint alleged the facility failed to change fall interventions after residents were identified at risk for falls. The complaint was investigated with no issues identified and a plan of correction in place.
Findings
The investigation found no issues with fall interventions after observations, record reviews, and interviews with residents, family members, and staff. A plan of correction with staff training was in place.
Report Facts
Facility census: 32
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Keeli Klein | Registered Nurse | Representative conducting the complaint investigation |
| Joseph Schumacher | Registered Nurse | Representative conducting the complaint investigation |
| Eve Lewis | Program Manager | Signed the inspection report |
Inspection Report
Annual Inspection
Census: 31
Capacity: 70
Deficiencies: 18
Date: Jun 11, 2015
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Crest View Healthcare Community from June 8, 2015 to June 11, 2015.
Complaint Details
The complaint investigation substantiated rudeness by a nurse to a resident. The incident was not reported to the State Agency as required.
Findings
The survey identified multiple deficiencies including failure to ensure resident privacy during wound care, failure to provide appropriate notice for involuntary discharge, failure to report allegations of abuse, failure to maintain dignity with mechanical lift slings, housekeeping and maintenance issues, incomplete care plans, failure to update care plans after incidents, unsafe environment hazards, food safety violations, infection control issues, and life safety code violations related to smoke barriers and emergency lighting.
Deficiencies (18)
Failure to ensure resident privacy during wound care by not draping resident during procedure.
Failure to provide written notice for involuntary discharge for one resident.
Failure to report an allegation of abuse to the State Agency within required timeframe.
Failure to maintain dignity by not properly managing mechanical lift slings in view of others.
Failure to ensure housekeeping cleaned soiled wall by resident's bed.
Failure to develop and revise comprehensive care plans to address fractured hip, safe transfers, pressure ulcer care, fall interventions, anticoagulant use, and antidepressant use.
Failure to ensure treatment and services to prevent and heal pressure sores including limiting layers between pressure relieving surfaces and skin and monitoring air mattress settings.
Failure to ensure resident environment free of accident hazards by not turning off oxygen concentrators when resident not in room.
Failure to provide food prepared by methods that conserve nutritive value, flavor, and appearance; and food that is palatable, attractive, and at the proper temperature, including presence of expired food items.
Failure to procure, store, prepare and serve food under sanitary conditions including dirty utensil drawer, food crumbs in clean plate storage, and unlabeled syrup containers.
Failure to establish and maintain an infection control program including failure to label resident towel bars and uncovered urinal increasing risk of cross contamination.
Failure to provide a safe, functional, sanitary, and comfortable environment including dripping faucets and soiled call light strings.
Failure to provide adequate outside ventilation in resident bathrooms.
Failure to ensure nurse aide registry verification and retraining including allowing a nursing assistant to work with a lapsed certification.
Failure of Quality Assessment and Assurance Committee to identify and correct quality of care issues prior to survey.
Failure to provide smoke barriers free of void spaces in attic above resident sleeping room corridors.
Failure to provide emergency lighting system that operates automatically during power interruption.
Failure to provide electrical wiring and equipment meeting National Electrical Code requirements including electrical outlet box too low in oxygen storage room.
Report Facts
Facility census: 31
Facility licensed capacity: 70
Number of expired food items: 6
Number of syrup squeeze bottles unlabeled: 7
Number of residents with mechanical lift sling dignity issues: 3
Number of residents with unlabeled towel bars: 14
Number of residents with bathroom vents not working: 4
Number of residents with stained call light strings: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in wound care privacy deficiency |
| NA B | Nursing Assistant | Named in wound care privacy deficiency |
| NA C | Nursing Assistant | Named in background check and abuse training deficiencies |
| NA F | Nursing Assistant | Named in background check, abuse training, and lapsed certification deficiencies |
| NA G | Nursing Assistant | Named in background check deficiency |
| LPN E | Licensed Practical Nurse | Named in abuse allegation investigation and medication administration |
| Director of Nursing | Director of Nursing | Named in multiple deficiencies including abuse investigation, care plan review, and wound care |
| Administrator | Facility Administrator | Named in multiple deficiencies including abuse investigation, care plan review, and QA&A oversight |
| Social Worker | Social Worker | Named in abuse investigation and involuntary discharge |
| Dietary Manager | Interim Dietary Manager | Named in food safety and sanitation deficiencies |
| Maintenance Personnel | Maintenance Personnel | Named in smoke barrier and emergency lighting deficiencies |
| Maintenance Director | Maintenance Director | Named in bathroom ventilation deficiency |
| Housekeeping Supervisor | Housekeeping Supervisor | Named in call light string and housekeeping deficiencies |
| Physical Therapist | Physical Therapist | Named in care plan and therapy progress |
| Physical Therapy Assistant | Physical Therapy Assistant | Named in care plan and therapy progress |
| Occupational Therapist | Occupational Therapist | Named in care plan and therapy progress |
Inspection Report
Complaint Investigation
Census: 23
Capacity: 70
Deficiencies: 9
Date: Jun 26, 2014
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Crest View Healthcare Community on June 24-26, 2014. The complaint alleged the facility failed to ensure residents were able to make choices regarding their pharmacy services.
Complaint Details
The complaint alleged the facility failed to ensure residents were able to make choices regarding their pharmacy services. The investigation confirmed that residents chose a local pharmacy but the facility did not honor their choices.
Findings
The facility failed to honor residents' choices for pharmacy services for multiple residents. Additional deficiencies included unclean bathroom vents, failure to ensure dentures were worn as per care plan, improper storage of oxygen e-tank, medication administration errors due to insufficient label verification, outdated medication not discarded, damaged wheelchair armrest, and fire safety code violations related to corridor fire separation and door closures.
Deficiencies (9)
Facility failed to ensure residents' choice for pharmacy services was honored for multiple residents.
Bathroom vents were not clean for four sampled residents.
Resident dentures were not in place for meals as directed on care plan.
E-tank filled with oxygen was stored improperly on floor without cylinder holder.
Prescription labels were not compared to physician orders at least three times before medication administration.
Outdated medication was not discarded for one resident.
Wheelchair armrest was cracked and torn, not replaced.
Facility failed to maintain one-hour fire separation of corridor due to void spaces in sheetrock ceiling above suspended ceiling.
Doors between corridors and hazardous areas did not close and latch properly when released from magnetic hold open device.
Report Facts
Facility census: 23
Facility licensed capacity: 70
Number of void spaces in ceiling: 6
Number of residents affected by bathroom vent issue: 4
Number of residents affected by denture issue: 1
Number of residents affected by oxygen e-tank issue: 1
Number of residents affected by medication label verification issue: 5
Number of residents affected by outdated medication: 1
Number of residents affected by wheelchair armrest issue: 1
Number of residents in corridor affected by fire door issue: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Tanner | Administrator | Confirmed pharmacy services did not honor residents' choices |
| Eve Lewis | Program Manager | Signed complaint investigation letter |
| Keeli Klein | Registered Nurse | Surveyor conducting complaint investigation |
| Joseph Schumacher | Registered Nurse | Surveyor conducting complaint investigation |
| Kaylene Straetker | Registered Nurse | Surveyor conducting complaint investigation |
| NA-A | Nurse Aide | Provided direct care to Resident 13 and described denture care routine |
| LPN-E | Licensed Practical Nurse | Observed administering medications and confirmed medication label verification deficiency |
| Maintenance Director | Confirmed wheelchair armrest needed replacement and fire safety deficiencies | |
| Director of Nursing | Confirmed multiple deficiencies including medication administration, denture care, oxygen tank storage, and maintenance reporting |
Inspection Report
Annual Inspection
Census: 24
Deficiencies: 8
Date: Jul 24, 2013
Visit Reason
The inspection was conducted as an annual survey to assess compliance with state and federal regulations governing skilled nursing facilities, nursing facilities, and intermediate care facilities.
Findings
The facility was found deficient in multiple areas including failure to report and investigate alleged abuse properly, failure to ensure resident choice in bathing and rising times, inaccurate resident assessments, incomplete care plans, improper food storage, and medication management issues including lack of monitoring and documentation.
Deficiencies (8)
Failure to submit investigation findings to the State Agency regarding an allegation of staff to resident abuse.
Failure to ensure residents were given choice in bathing frequency and rising times.
Failure to accurately code resident assessments to identify hemiparesis.
Failure to develop comprehensive care plans addressing hemiparesis and potential dehydration risks.
Failure to provide accurate and consistent skin and wound assessments.
Failure to ensure drug regimen was free from unnecessary drugs including lack of monitoring digoxin levels, unclear diagnoses for medications, and lack of justification for duplicate diuretic therapy.
Failure to ensure walk-in freezer was in working order and contents remained frozen.
Failure to ensure medications were reviewed for allergies and documentation of allergy versus intolerance was lacking.
Report Facts
Facility census: 24
Walk-in freezer temperature: 49
Walk-in freezer temperature: 50
Fine amount: No fine amount stated
Inspection Report
Annual Inspection
Census: 30
Deficiencies: 7
Date: Jun 28, 2012
Visit Reason
The inspection was the annual survey of Crest View Care Center to assess compliance with Nebraska regulations governing licensure of skilled nursing facilities, nursing facilities, and intermediate care facilities.
Findings
The facility was found deficient in housekeeping and maintenance services, assessment accuracy, development of comprehensive care plans, provision of care and services for highest well-being, accident hazard prevention, drug records and storage, and infection control. Specific issues included non-functioning bathroom vents, stained carpet, inaccurate coding of pressure ulcers, incomplete care plans, lack of follow-up on skin tear assessments, unsafe grab bars, expired stock medications, and potential cross-contamination during laundry delivery.
Deficiencies (7)
Bathroom vents were not functioning for three residents and carpet was stained for one resident.
Failed to accurately code pressure ulcer progress and use of pressure relieving mattress for one resident.
Failed to develop comprehensive care plans addressing specialty mattress use and dental care for sampled residents.
Failed to follow up with assessments of a skin tear for one resident.
Failed to assess safety of assist grab bars on beds for three residents.
Failed to dispose of expired stock medications (Bisacodyl and Tylenol suppositories).
Failed to prevent potential cross contamination of laundered clothing during delivery.
Report Facts
Facility census: 30
Stage 2 sample size: 9
Expired medication date: 2010.1
Expired medication date: 2012.01
Skin tear size: 0.5
Skin tear size: 2
Grab bar width: 4
Grab bar height from mattress: 6
Grab bar height from mattress: 8
Inspection Report
Routine
Census: 31
Deficiencies: 2
Date: Apr 10, 2012
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory standards for skilled nursing facilities, including pharmaceutical services and nursing care plan requirements.
Findings
The facility failed to complete a preliminary nursing care plan within 24 hours of admission for one sampled resident and failed to obtain narcotic medication in a timely manner for another resident, resulting in delayed administration of pain medication.
Deficiencies (2)
Failure to complete a preliminary nursing care plan within 24 hours of admission for one sampled resident.
Failure to obtain narcotic medication when ordered for one sampled resident, resulting in delayed administration.
Report Facts
Facility census: 31
Sample size: 3
Sample size: 2
Date of resident admission: Feb 27, 2012
Date of physician order: Mar 9, 2012
Date of first dose administered: Mar 10, 2012
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN-A | Registered Nurse | Added narcotic medication order and administered first dose to Resident 2 |
| Director of Nursing | Director of Nursing | Confirmed initial care plan was not completed and verified medication delay |
Inspection Report
Routine
Census: 29
Deficiencies: 1
Date: Jun 28, 2011
Visit Reason
The inspection was conducted to evaluate compliance with regulations governing licensure of skilled nursing facilities, nursing facilities, and intermediate care facilities, focusing on accident hazards, supervision, and devices to prevent resident falls.
Findings
The facility failed to identify causal factors related to recurrent falls and did not review or revise interventions to prevent recurrent falls for 4 sampled residents. Multiple incidents of falls were documented with inadequate follow-up and ineffective use of personal alarms. The facility policy on fall management was not fully implemented, and care plans did not consistently address actual falls.
Deficiencies (1)
Facility failed to identify causal factors related to recurrent falls and failed to review and revise interventions to prevent recurrent falls for 4 sampled residents.
Report Facts
Facility census: 29
Fall Risk Assessment score: 22
Fall Risk Assessment score: 11
Fall Risk Assessment score: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN (Registered Nurse) - A, Charge Nurse | Interviewed regarding Resident 3's personal alarm use | |
| DON (Director of Nursing) | Interviewed confirming missing fall risk assessment and ineffective fall interventions | |
| Administrator | Interviewed confirming staff did not identify causal factors for falls or implement effective interventions |
Inspection Report
Annual Inspection
Census: 30
Capacity: 30
Deficiencies: 9
Date: May 4, 2011
Visit Reason
The inspection was conducted as a standard annual survey to assess compliance with regulations governing licensure of skilled nursing facilities, nursing facilities, and intermediate care facilities.
Findings
The facility was found deficient in multiple areas including failure to update care plans for residents, inadequate assessment and follow-up of allergy symptoms, lack of indication and monitoring for medications, failure to discard expired food items, improper medication administration practices, and fire safety code violations related to door closures and corridor obstructions.
Deficiencies (9)
Failed to update the care plan for Resident 10 to clarify interventions related to denture use.
Failed to assess and follow up with ongoing allergy symptoms for Resident 49.
Failed to ensure all medications had an indication for use and that gradual dose reduction requests were addressed for Resident 4.
Failed to discard expired single use milk cartons resulting in expired milk being served to Resident 19.
Failed to ensure the pharmacist identified medication irregularities and monitored psychotropic medications for Resident 4.
Failed to develop a preliminary nursing care plan within 24 hours of admission for Resident 37.
Failed to observe residents swallow prescribed supplements for Residents 3 and 12.
Failed to provide corridor doors that closed properly upon fire alarm activation.
Failed to maintain aisles and corridors clear and unobstructed to facilitate exit during emergency.
Report Facts
Facility census: 30
Sample size: 26
Deficiency count: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding care plan and allergy symptom deficiencies | |
| Charge Nurse | Interviewed regarding allergy symptom follow-up and medication administration | |
| Consulting Pharmacist | Interviewed regarding medication regimen review and dose reduction | |
| Administrator | Interviewed regarding expired milk and fire door deficiencies | |
| Registered Nurse A | Observed administering supplements without observing swallowing |
Notice
Capacity: 70
Deficiencies: 0
Date: APP2019
Visit Reason
This document serves to verify the renewal of the SNF/NF dual certification license for Crest View Care Center and includes the occupancy permit indicating the maximum licensed capacity of the facility.
Findings
The facility is licensed through 3/31/2020 with a total licensed capacity of 70 beds, as confirmed by the renewal application and occupancy permit issued by the Nebraska State Fire Marshal.
Report Facts
Licensed capacity: 70
Renewal expiration date: License expiration date is 2020-03-31.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary McCoy | Director of Nursing | Named as Director of Nursing on the renewal application. |
| Keith Sladky | Administrator | Named as Administrator on the renewal application. |
| Bo Botslho | Interim Director, Division of Public Health | Signed the license renewal verification. |
Notice
Capacity: 70
Deficiencies: 0
Date: APP2021
Visit Reason
This document serves as a renewal application and verification of licensure for Crest View Care Center, confirming the facility's license status and renewal fees.
Findings
The documents confirm that Crest View Care Center meets statutory requirements for licensure renewal, including occupancy permit details and ownership information.
Report Facts
Renewal Licensure Fee: 1750
Total Capacity: 70
Notice
Capacity: 70
Deficiencies: 0
Date: APP2022
Visit Reason
The documents serve to verify the licensure renewal of Crest View Care Center as a skilled nursing facility and to provide a temporary occupancy permit.
Findings
The documents confirm that Crest View Care Center meets statutory requirements for licensure renewal and has a temporary occupancy permit valid through 12/31/2022 with a maximum occupancy of 70 beds.
Report Facts
Maximum Occupancy: 70
Number of Beds to be Relicensed: 70
Renewal Expiration Date: Mar 31, 2023
Occupancy Permit Expiration Date: Dec 31, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Ellen Lantis | President | Named as President of Kismet CDR, LLC d.b.a. Crest View Care Center and authorized representative on renewal application. |
| Mike Moore | Treasurer and CFO | Named as Treasurer of Kismet CDR, LLC and CFO of Lantis Enterprises, Inc. |
| Cammy Lantis | Secretary and VP Risk Management and Secretary | Named as Secretary of Kismet CDR, LLC and VP Risk Management and Secretary of Lantis Enterprises, Inc. |
| Doug Hohbein | Deputy State Fire Marshal | Inspected the facility and approved the temporary occupancy permit. |
Notice
Capacity: 70
Deficiencies: 0
Date: APP2023
Visit Reason
This document package serves to verify the renewal of the SNF/NF dual certification license for Crest View Care Center, including submission of the Nursing Home Licensure Renewal Application and related ownership and occupancy permit information.
Findings
No inspection findings are reported. The documents confirm licensure renewal, ownership details, and occupancy permit status for the facility.
Report Facts
Total licensed beds: 70
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Heather Salmon | Administrator | Named in the Nursing Home Licensure Renewal Application. |
| Patricia Annetts | Director of Nursing | Named in the Nursing Home Licensure Renewal Application. |
| Mary Ellen Lantis | President | Listed as President of Kismet CDR, LLC and Management Company in ownership/control documents. |
| Mike Moore | Treasurer and CFO | Listed as Treasurer of Kismet CDR, LLC and CFO of Management Company in ownership/control documents. |
| Cammy Lantis | Secretary and VP Risk Management | Listed as Secretary of Kismet CDR, LLC and VP Risk Management and Secretary of Management Company in ownership/control documents. |
| Wendy Soulek | COO | Listed as COO of Management Company in ownership/control documents. |
| Leah Rinard | VP Outsourcing and HR | Listed as VP Outsourcing and HR of Management Company in ownership/control documents. |
Notice
Capacity: 70
Deficiencies: 0
Date: APP2024
Visit Reason
The document serves as a renewal application and verification of licensure for Crest View Care Center as a Skilled Nursing Facility with 70 beds, including related occupancy permits and ownership information.
Findings
The documents confirm the facility's licensure renewal status, ownership details, and occupancy permit with a maximum capacity of 70 beds. No inspection findings or deficiencies are reported.
Report Facts
Total licensed beds: 70
Renewal licensure fees: 1550
Renewal licensure fees: 1750
Renewal licensure fees: 1950
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Helen Wichman | Administrator | Named on Nursing Home Licensure Renewal Application |
| Deneane Beard | Director of Nursing | Named on Nursing Home Licensure Renewal Application |
| Mary Ellen Lantis | President | President of Kismet CDR, LLC and Lantis Enterprises, Inc. |
| Mike Moore | Treasurer and CFO | Treasurer of Kismet CDR, LLC and CFO of Lantis Enterprises, Inc. |
| Cammy Lantis | Secretary and VP Risk Management | Secretary of Kismet CDR, LLC and VP Risk Management and Secretary of Lantis Enterprises, Inc. |
| Wendy Soulek | COO | COO of Lantis Enterprises, Inc. |
| Leah Rinard | VP Outsourcing and HR | VP Outsourcing and HR of Lantis Enterprises, Inc. |
Notice
Capacity: 70
Deficiencies: 0
Date: APP2025
Visit Reason
This document serves as a renewal application and verification of licensure for Crest View Care Center, confirming the facility meets statutory requirements and is licensed through the indicated renewal date.
Findings
The documents confirm the facility's licensure renewal, ownership information, and occupancy permit with no inspection findings or deficiencies noted.
Report Facts
Total licensed beds: 70
Renewal license expiration date: 2026
Occupancy permit issue date: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Helen Wichman | Administrator | Named on renewal application. |
| Shelly Wynia | Director of Nursing | Named on renewal application. |
| Mary Ellen Lantis | President | Named in ownership and management company information. |
| Mike Moore | Treasurer and CFO | Named in ownership and management company information. |
| Cammy Lantis | Secretary and VP Risk Management | Named in ownership and management company information. |
| Wendy Soulek | COO | Named in management company information. |
Document
Capacity: 70
Deficiencies: 0
Date: CHOW2018
Visit Reason
This document set includes licensing verification, ownership and operating agreements, and a Memorandum of Understanding regarding the transfer of operations and ownership of Crest View Care Center and affiliated facilities.
Findings
The documents confirm the licensing status, ownership structure, and detailed terms of the operational transfer between Welcov Healthcare, LLC and Lantis Enterprises, Inc., including lease terminations, transfer of assets, employee obligations, and indemnifications.
Report Facts
Total licensed capacity: 70
Initial licensing fee: 1550
Number of beds to be licensed: 70
License expiration date: Mar 31, 2019
Licensure issuance date: Sep 1, 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cathy Snyder | Administrator | Named as facility administrator in licensure application on page 4. |
| Michelle Reitz | Director of Nursing | Named as director of nursing in licensure application on page 4. |
| Courtney N. Phillips | Chief Executive Officer | Signed licensure issuance letter on page 3. |
| Dan Taylor | RN, Training Coordinator | Contact person for licensing questions in letter on page 3. |
| Paul Contris | CEO | Named as CEO of Welcov Healthcare, LLC and signatory on Memorandum of Understanding pages 36-38. |
| Travis Lantis | President/Manager/Co-Manager | Named as President of Lantis Enterprises, Inc. and signatory on Memorandum of Understanding pages 31-35. |
| Mary Ellen Lantis | President | Named as President of Lantis Enterprises, Inc. and signatory on Memorandum of Understanding pages 31-33. |
| Michael Moore | Manager | Named as Manager and signatory on Memorandum of Understanding pages 32-35. |
Notice
Deficiencies: 0
Date: DAN122225
Visit Reason
This Notice of Disciplinary Action informs Crest View Care Center of probation for 90 days beginning January 6, 2026, due to violations related to failure to determine root causes of falls and implement interventions to prevent falls.
Findings
The facility failed to identify residents at risk for falls and implement effective interventions, resulting in disciplinary action and a requirement to submit a Plan of Correction and weekly reports on residents with falls during the probation period.
Report Facts
Probation period length: 90
Report due date: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Timothy Tesmer | Chief Medical Officer | Signed the Notice of Disciplinary Action |
| Kolby Venger | Administrative Specialist | Certified mailing of the Notice of Disciplinary Action |
Notice
Capacity: 70
Deficiencies: 0
Date: APP2016
Visit Reason
This document serves as a licensure renewal application and certification for Crest View Healthcare Community, verifying the facility's license renewal and occupancy permit status.
Findings
The documents confirm the facility meets statutory requirements for licensure renewal as a Skilled Nursing Facility with a total capacity of 70 beds. No inspection findings or deficiencies are reported.
Report Facts
Total licensed beds: 70
Renewal fees: 1750
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cathy Snyder | Administrator | Named on Nursing Home Licensure Renewal Application. |
| Anna Stetson | Director of Nursing | Named on Nursing Home Licensure Renewal Application. |
Document
Capacity: 70
Deficiencies: 0
Date: APP2018
Visit Reason
The document serves as a renewal application for the nursing home license of Crest View Healthcare Community, including verification of licensure and occupancy permit information.
Findings
The documents confirm that Crest View Healthcare Community is licensed as a Skilled Nursing Facility/Nursing Facility with a total licensed capacity of 70 beds. The occupancy permit was issued on 2017-06-13 and the license renewal is valid through 2019-03-31.
Report Facts
Total licensed capacity: 70
License expiration date: License expires on 2019-03-31 as indicated on renewal card.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Cathy Snyder | Administrator | Named in the nursing home licensure renewal application. |
| Tanya Wilson | Director of Nursing | Named in the nursing home licensure renewal application. |
| Thomas E. Boerboom | Authorized representative signing the renewal application. | |
| Paul J. Contris | CEO | Authorized representative signing the renewal application. |
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