Deficiencies (last 4 years)
Deficiencies (over 4 years)
10 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
138% worse than Nebraska average
Nebraska average: 4.2 deficiencies/yearDeficiencies per year
24
18
12
6
0
Occupancy
Latest occupancy rate
83% occupied
Based on a March 2019 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Notice
Capacity: 72
Deficiencies: 0
Date: Mar 25, 2025
Visit Reason
This document serves as a renewal application for the nursing home license of Hillcrest Firethorn, including verification of licensure and occupancy permit information.
Findings
The documents confirm that Hillcrest Firethorn is licensed as a Skilled Nursing Facility with 72 licensed beds and meets statutory requirements for licensure renewal. An occupancy permit was issued confirming the maximum occupancy of 72 beds.
Report Facts
Number of beds to be relicensed: 72
Maximum Occupancy: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staci Svengard | Administrator | Named in Nursing Home Licensure Renewal Application |
| Kristina Wilson | Director of Nursing | Named in Nursing Home Licensure Renewal Application |
| Matthew Oestmann | Authorized Representative | Signed Nursing Home Licensure Renewal Application |
| Reggie Ripple | Authorized Representative | Signed Nursing Home Licensure Renewal Application |
| Susen Lindner | Deputy State Fire Marshal | Inspected and approved Nebraska State Fire Marshal Occupancy Permit |
Notice
Deficiencies: 0
Date: Feb 20, 2025
Visit Reason
This Notice of Disciplinary Action was issued due to violations related to the facility's failure to provide the outlined bowel management program and instead providing digital stimulation, as evidenced by the CMS-2567 Report dated February 20, 2025.
Findings
The facility was placed on probation for 90 days starting March 19, 2025, and must submit a Plan of Correction addressing urinary and bowel function violations, including assessment methods, interventions, and evaluation processes. Failure to comply may result in further disciplinary action.
Report Facts
Probation period: 90
Report date: Feb 20, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Timothy Tesmer | Chief Medical Officer | Signed the Notice of Disciplinary Action |
| Dan Taylor | Administrator | Health Facilities Licensure Unit contact |
| Linda Stenvers | Administrative Specialist | Certified mailing of the Notice |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 18, 2019
Visit Reason
An unannounced visit was conducted to investigate a complaint regarding the facility's failure to ensure staff are educated about emergency notification policies and procedures.
Complaint Details
The complaint alleged failure to ensure staff education on emergency notification policies. The investigation found the allegation unsubstantiated and the facility compliant.
Findings
The facility was found to be in compliance with regulations; staff were educated on emergency notification policies and procedures, and no concerns were identified through interviews, grievances, or record reviews.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Connie Vogt | Program Manager | Signed the report as Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 30, 2019
Visit Reason
An unannounced visit was conducted to investigate a complaint regarding the facility's failure to use appropriate interventions to prevent injuries from falls.
Complaint Details
The complaint alleged failure to use appropriate interventions to prevent injuries from falls. The facility was determined to be in compliance with related regulatory requirements.
Findings
The facility was found to have used appropriate interventions to prevent injuries from falls. Observations, record reviews, and staff interviews confirmed that falls were evaluated and care planned interventions were implemented, resulting in compliance with regulatory requirements.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Connie Vogt | Program Manager | Signed the report as Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS |
Inspection Report
Annual Inspection
Census: 60
Capacity: 72
Deficiencies: 22
Date: Mar 18, 2019
Visit Reason
An unannounced visit was conducted to investigate a complaint and annual survey at Hillcrest Firethorn on March 11-18, 2019 by representatives of the Department of Health and Human Services Division of Public Health.
Complaint Details
Complaint allegations included failure to provide care according to practitioner's orders, insufficient staffing, medication errors, failure to report crimes and misappropriation, call system issues, food temperature and timeliness, and pain management. Some allegations were substantiated including medication administration errors and securing narcotic medications.
Findings
The facility was found deficient in multiple areas including medication administration errors, failure to notify families of changes in plan of care, incomplete documentation of transfers and discharges, inaccurate resident assessments, incomplete care plans, improper medication storage and labeling, infection control practices, food safety, fire safety, and hazardous area door maintenance.
Deficiencies (22)
Facility failed to notify family of changes in plan of care for Resident 47.
Facility failed to document basis for transfer and resident condition at time of discharge for Resident 26.
Facility failed to notify Resident 26 or representative of transfer and reason in writing and failed to notify Ombudsman.
Facility failed to notify Resident 26 and Resident 47 of bed hold policy in writing.
Facility failed to transmit Resident 14's discharge MDS to CMS within 14 days.
Facility failed to accurately document MDS for Residents 1, 17, 43, 34, and 37 including immunizations, GT use, CPAP use, and pressure ulcer risk.
Facility failed to complete baseline care plan within 48 hours of admission for Resident 223.
Facility failed to develop and implement comprehensive care plan for Residents 37 and 47 including measurable objectives and timeframes.
Facility failed to review and revise comprehensive care plans for Residents 171, 47, and 17 related to skin integrity and bed rails and failed to notify family of care plan meeting for Resident 47.
Facility failed to review risks and benefits of bed rails, obtain consent, and assess for entrapment for Resident 47.
Facility failed to properly label stock and emergency medications, and narcotics were left unsecured affecting Resident 33.
Facility failed to ensure PRN psychotropic medication orders had rationale to continue past 14 days for Resident 3.
Facility medication error rate was 11%, exceeding 5%, including insulin dosing errors for Residents 23 and 132.
Facility failed to ensure hair restraints fully covered facial hair, handwashing was inadequate, floors were sticky, and spoiled food was present in kitchen.
Facility failed to ensure resident had divided plate per dietary recommendation for Resident 38.
Facility failed to ensure handwashing and gloving were performed properly and PICC line dressings were not dated, timed or initialed for Resident 173.
Facility failed to ensure influenza and pneumococcal immunizations were properly offered, documented, and not duplicated for Residents 1, 17, 43, 47, and 223.
Facility failed to maintain doors and ceilings in hazardous areas, allowing smoke migration into exit corridor.
Facility failed to maintain wheeled appliances under kitchen hood in proper location to ensure fire suppression system coverage.
Facility failed to ensure corridor doors were not obstructed from closing, delaying egress.
Facility failed to conduct fire drills on all shifts each quarter.
Facility failed to post 'Oxygen in Use, No Smoking' signs on rooms where oxygen was administered.
Report Facts
Medication error rate: 11
Facility census: 60
Total capacity: 72
Pressure ulcer size: 2.5
Pressure ulcer size: 2
Pressure ulcer size: 2.5
Pressure ulcer size: 1
Medication dose error: 2
Vitamin D3 dose error: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Connie Vogt | Program Manager - Office of LTC Facilities - Licensure Unit | Signed the initial complaint investigation letter. |
| Rebecca Smith | Administrator | Facility administrator named in the report. |
| Director of Nursing | Interviewed multiple times regarding care plan, medication errors, and facility practices. | |
| Clinical Care Coordinator F | Interviewed regarding care plans, wound care, and medication administration. | |
| Director of Clinical Services | Responsible for compliance and monitoring corrective actions. | |
| Director of Environmental Services | Responsible for monitoring bed safety and door compliance. | |
| Director of Culinary Services | Responsible for food safety and assistive device compliance. | |
| Registered Nurse B | Observed medication pass and confirmed medication labeling issues. | |
| Licensed Practical Nurse E | Observed medication pass and insulin administration error. | |
| Clinical Care Coordinator D | Interviewed regarding medication storage and labeling. | |
| Dietary Manager | Interviewed regarding food safety and hair restraint policies. | |
| MDS Coordinator | Interviewed regarding MDS submission and accuracy. | |
| Administrator | Interviewed regarding fire drills and facility policies. | |
| Maintenance Staff A | Interviewed regarding door and oxygen signage deficiencies. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 3, 2019
Visit Reason
An unannounced visit was conducted to investigate a complaint at Hillcrest Firethorn on January 3, 2019, by representatives of the Department of Health and Human Services Division of Public Health.
Complaint Details
The complaint alleged failure to implement care planned fall interventions and failure to complete written investigations within five working days. Both allegations were found to be unsubstantiated.
Findings
The facility was found to be in compliance with regulations regarding care planned fall interventions and timely completion of written investigations within five working days. No violations were identified related to the allegations.
Report Facts
Records reviewed: 3
Investigation completion timeframe: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Connie Vogt | Program Manager | Signed the report as Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS |
Inspection Report
Complaint Investigation
Census: 30
Deficiencies: 8
Date: Jun 12, 2018
Visit Reason
An unannounced visit was conducted to investigate a complaint at Hillcrest Firethorn on June 12-14, 2018, by representatives of the Department of Health and Human Services Division of Public Health.
Complaint Details
The complaint investigation included allegations of failure to protect residents from abuse, failure to answer call notification systems promptly, failure to provide care and services according to practitioner's orders, failure to immediately report allegations of abuse, failure to notify the department of changes in administrative staff in 5 working days, failure to protect the resident from verbal abuse, failure to provide wound care as ordered, failure to provide transportation as agreed upon, failure to administer medications as ordered, failure to ensure residents receive specialized treatments, failure to provide sufficient supervision to prevent elopement, failure to report incidents of elopement, failure to provide bowel care and assessment, failure to ensure documentation is accurate and complete, failure to provide bathing as required, and failure to identify causal factors in falls. Several allegations were found unsubstantiated or compliant, but multiple deficiencies were cited.
Findings
The investigation found multiple deficiencies including failure to provide care and services according to practitioner's orders, failure to notify the department of changes in administrative staff within 5 working days, failure to administer medications as ordered, failure to ensure residents receive specialized treatments as ordered, and failure to ensure documentation is accurate and complete. Other allegations such as abuse, call system response, wound care, transportation, elopement supervision and reporting, bowel care, bathing, and fall causal factor identification were found to be compliant.
Deficiencies (8)
Failure to provide care and services according to practitioner's orders.
Failure to notify the department of changes in administrative staff in 5 working days.
Failure to administer medications as ordered.
Failure to ensure residents receive specialized treatments as ordered or per standards of practice.
Failure to ensure documentation is accurate and complete.
Medication error rate of 23.8% observed affecting 3 residents.
Failure to ensure residents are free of significant medication errors.
Failure to notify the State Agency of two changes in the Director of Nursing within 5 working days.
Report Facts
Deficiency count: 8
Medication error rate: 23.8
Residents affected by medication errors: 3
Residents sampled for medication administration: 21
Facility census: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Kezar | Administrator | Named as facility administrator in multiple documents. |
| Dan Taylor | RN, Training Coordinator | Author of the complaint investigation report and correspondence. |
| RN-A | Acting Director of Nursing Services | Interviewed regarding medication administration and DON changes. |
| RN-B | Director of Nursing (former) | Listed as DON by State Agency but no longer employed. |
| RN-C | Director of Nursing (former) | Former DON no longer employed by facility. |
| LPN-E | Licensed Practical Nurse | Observed administering medications with errors. |
| Dain Weiss | RN, Reviewer | Conducted Informal Conference and authored report affirming deficiency. |
| Becky Wisell | Administrator, Licensure Unit | Sent notification of decision following Informal Conference. |
Inspection Report
Re-Inspection
Census: 1
Capacity: 72
Deficiencies: 5
Date: Dec 11, 2017
Visit Reason
A revisit survey was conducted to verify correction of previous deficiencies cited on 12/01/17.
Findings
All previously cited deficiencies have been corrected, and no new noncompliance was found. The facility is in compliance with applicable provisions of the 2012 Edition of the National Fire Protection Association Life Safety Code.
Deficiencies (5)
Egress doors were not equipped with proper signage and locking mechanisms as required by NFPA 101 Life Safety Code.
Fire watch policy lacked notification requirements for insurance carrier, alarm company, property owner, and authorities.
Fire rated smoke doors had undercut gaps exceeding 3/4 inch.
Generator maintenance lacked a comprehensive weekly checklist.
Oxygen storage room lacked appropriate signage regarding transfilling and smoking restrictions.
Report Facts
Licensed beds: 72
Census: 1
Deficiencies cited: 5
Notice
Capacity: 72
Deficiencies: 0
Date: Dec 7, 2017
Visit Reason
Notification of acceptance of Hillcrest Firethorn skilled nursing facility to participate under the Medicare Health Insurance Benefits Program, effective December 7, 2017.
Findings
The document outlines the terms of Medicare participation, including the requirement for ongoing unannounced surveys, submission of plans of correction for any deficiencies, and compliance with Civil Rights requirements.
Report Facts
Medicare certified beds: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dan Taylor | Program Manager - Office of LTC Facilities - Licensure Unit - Division of Public Health - DHHS | Signed the acceptance letter regarding Medicare participation. |
Inspection Report
Life Safety
Census: 1
Capacity: 72
Deficiencies: 5
Date: Dec 1, 2017
Visit Reason
The survey was conducted to assess compliance with the Life Safety Code and related Medicare/Medicaid participation requirements.
Findings
The facility was found not in compliance with several Life Safety Code provisions including missing signage on delayed egress doors, incomplete fire watch policy notifications, excessive undercuts on smoke barrier doors, incomplete emergency generator maintenance documentation, and missing precautionary signage in the oxygen transfilling room.
Deficiencies (5)
Failed to provide signage describing operation of delayed egress doors on exit doors in 1 of 6 smoke compartments.
Incomplete fire watch policy lacking notification requirements to insurance carrier, alarm company, property owner, and authorities.
Corridor separation doors had undercuts greater than 3/4 inch in 5 of 6 smoke compartments, compromising smoke barrier integrity.
Failed to conduct and document weekly inspections of all emergency generator components including lubrication, exhaust, electrical system, belts, hoses, prime mover, water pump, jacket water heater, radiator, cool down time, and transfer time.
Failed to post precautionary sign in liquid oxygen transfilling room to alert occupants of ignition hazards.
Report Facts
Facility census: 1
Total licensed beds: 72
Number of smoke compartments: 6
Undercut measurement: 0.75
Date survey completed: Dec 1, 2017
Notice
Capacity: 72
Deficiencies: 0
Date: APP2021
Visit Reason
The document serves to verify and renew the SNF/NF dual certification license for Hillcrest Firethorn nursing home and includes related ownership and occupancy information.
Findings
The documents confirm the facility's licensure renewal status, ownership details, and maximum licensed bed capacity of 72 beds. No inspection findings or deficiencies are reported.
Report Facts
Total licensed beds: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Barry Emerson | Administrator | Listed as Administrator in renewal application. |
| Kristina Watson | Director of Nursing | Listed as Director of Nursing in renewal application. |
| Sharyl Ronan | CEO | Signed renewal application as authorized representative. |
| Kevin Mulhearn | CFO | Signed renewal application and ownership disclosure as authorized representative. |
| Derrick DeFino | VP of Facility Based Operations | Listed in management employee section. |
Document
Capacity: 72
Deficiencies: 0
Date: APP2022
Visit Reason
This document serves as a licensure renewal application for Hillcrest Firethorn nursing home facility and includes certification of licensure, ownership disclosure, and occupancy permit.
Findings
The documents confirm the facility's licensure renewal status, ownership information, and maximum licensed bed capacity of 72 beds. No inspection findings or deficiencies are reported.
Report Facts
Total licensed beds: 72
Renewal license fees: 1550
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Barry Emerson | Administrator | Named in licensure renewal application as facility administrator. |
| Kristine Watson | Director of Nursing | Named in licensure renewal application as director of nursing. |
| Kevin Mulhearn | Authorized representative signing ownership disclosure and certification forms. | |
| Sharyl Ronan | Authorized representative signing ownership disclosure and certification forms. |
Document
Capacity: 72
Deficiencies: 0
Date: APP2023
Visit Reason
The document set serves to verify and renew the licensure of Hillcrest Firethorn as a skilled nursing facility with 72 licensed beds.
Findings
No inspection findings or deficiencies are reported. The documents confirm licensure renewal, ownership information, and occupancy permit status.
Report Facts
Total licensed beds: 72
Renewal licensure fee: 1550
Renewal licensure fee: 1750
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Barry Emerson | Administrator | Named on the Nursing Home Licensure Renewal Application |
| Kristina Watson | Director of Nursing, R.N. | Named on the Nursing Home Licensure Renewal Application |
| Kevin Mulhearn | Authorized Representative | Signed the Nursing Home Licensure Renewal Application |
| James Janicki | Authorized Representative | Signed the Nursing Home Licensure Renewal Application |
| Susen Lindner | Deputy State Fire Marshal | Inspected the facility and approved the occupancy permit |
Notice
Capacity: 72
Deficiencies: 0
Date: APP2024
Visit Reason
This document serves as a renewal application for the nursing home license of Hillcrest Firethorn, including verification of licensure and occupancy permits.
Findings
The documents confirm the facility's licensure renewal status, ownership information, and maximum licensed bed capacity of 72 beds. No inspection findings or deficiencies are reported.
Report Facts
Total licensed beds: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staci Svendgard | Administrator | Named in the renewal application identifying information. |
| Kristina Watson | Director of Nursing | Named in the renewal application identifying information. |
Document
Capacity: 72
Deficiencies: 0
Date: APP2017
Visit Reason
The documents pertain to the licensing, renewal, and occupancy certification of Hillcrest Firethorn Skilled Nursing Facility, including initial license issuance and occupancy permit approval.
Findings
The facility is licensed as a Skilled Nursing Facility with a total licensed capacity of 72 beds. The occupancy permit was issued confirming compliance with fire marshal codes. Bed count forms confirm the licensed capacity and beds set up as 72.
Report Facts
Licensed beds: 72
License issuance date: Oct 18, 2017
Occupancy permit date: Oct 4, 2017
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Kezar | Administrator | Named as facility administrator in licensing application |
| Tiffany Weeks | Director of Nursing | Named as Director of Nursing in licensing application |
| Thomas L. Williams, MD | Chief Medical Officer, Director, Division of Public Health | Signed license issuance and renewal documents |
| Eve Lewis | RNC, Program Manager | Contact person for licensing questions |
| Jolene Roberts | Member of Hillcrest Firethorn LLC | |
| Tim Irwin | Member of Hillcrest Firethorn LLC | |
| Kevin Mulhearn | Member of Hillcrest Firethorn LLC |
Notice
Capacity: 72
Deficiencies: 0
Date: APP2018
Visit Reason
This document serves as a licensure renewal application and verification for the Skilled Nursing Facility license of Hillcrest Firethorn, including renewal fee payment and certification of compliance.
Findings
The documents confirm the facility's licensure renewal status, ownership information, and include a fire department operational permit with a maximum occupancy of 72 beds.
Report Facts
Total licensed beds: 72
Renewal fee amount: 1750
Maximum occupancy: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Joseph Kezar | Administrator | Named as the facility administrator in the renewal application on page 2. |
| Kris D'Ann Maples | In-House Counsel, Compliance Director | Signed the renewal application cover letter on page 3. |
| Kevin Mulhearn | CFO | Named as a member of Hillcrest Firethorn LLC in the renewal application letter on page 3. |
| Jolene Roberts | Named as a member of Hillcrest Firethorn LLC in the renewal application letter on page 3. |
Notice
Capacity: 72
Deficiencies: 0
Date: APP2019
Visit Reason
This document serves as verification of the renewal of the SNF/NF dual certification license for Hillcrest Firethorn and includes occupancy permits and licensing renewal application details.
Findings
The facility is licensed for 72 beds with a maximum occupancy of 72 residents. The renewal application and occupancy permits confirm compliance with licensing and fire safety requirements.
Report Facts
Licensed beds: 72
Renewal fee: 1750
Maximum occupancy: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Smith | Administrator | Named on renewal application |
| Suzanne Braaten | Director of Nursing | Named on renewal application |
| Susen Lindner | Deputy State Fire Marshal | Inspected and approved occupancy permit |
Notice
Capacity: 72
Deficiencies: 0
Date: APP2020
Visit Reason
This document serves as the Nursing Home Licensure Renewal Application for Hillcrest Firethorn, including verification of licensure status and occupancy permit details.
Findings
The documents confirm that Hillcrest Firethorn meets statutory requirements for licensure renewal as a Skilled Nursing Facility with a total licensed capacity of 72 beds. The Nebraska State Fire Marshal occupancy permit also confirms the maximum occupancy of 72 beds.
Report Facts
Total licensed beds: 72
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Rebecca Smith | Administrator | Named in ownership and management information on licensure renewal application |
| Kristina Watson | Director of Nursing | Named in licensure renewal application |
| Sharyl Ronan | CEO | Authorized representative signing ownership disclosure and licensure renewal application |
| Kevin Mulhearn | CFO | Authorized representative signing licensure renewal application |
| Derrick DeFino | VP of Facility Operations | Listed in ownership/management disclosure |
| Jolene Roberts | President | Listed in ownership/management disclosure |
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