A list of the most recent deficiencies for Hillcrest Manor Sanitarium. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-10-12 | 2023-11-30 | N |
| 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. | Health | 2023-10-12 | 2023-11-30 | N |
| Assess the resident when there is a significant change in condition | Health | 2023-10-12 | 2023-11-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-10-12 | 2023-11-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-12 | 2023-11-30 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-12 | 2023-11-30 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2023-10-12 | 2023-11-30 | N |
| 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. | Health | 2023-10-12 | 2023-11-30 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-10-12 | 2023-11-30 | N |
| 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. | Health | 2023-10-12 | 2023-11-30 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-10-12 | 2023-11-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-12 | 2023-11-30 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2023-10-12 | 2023-11-30 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2023-10-12 | 2023-11-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-10-17 | 2023-11-06 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2023-10-17 | 2023-11-06 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-10-17 | 2023-11-06 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2023-10-17 | 2023-11-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-17 | 2023-11-06 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-10-17 | 2023-11-06 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-17 | 2023-11-06 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2023-10-17 | 2023-11-06 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-10-17 | 2023-11-06 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-10-17 | 2023-11-06 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2023-10-17 | 2023-11-06 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-10-17 | 2023-11-06 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2022-09-26 | 2022-10-17 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-09-26 | 2022-10-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-09-26 | 2022-10-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-23 | 2022-09-30 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-09-23 | 2022-09-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-23 | 2022-09-30 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-09-23 | 2022-09-30 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2022-09-23 | 2022-09-30 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-09-23 | 2022-09-30 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-06-02 | 2022-07-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-27 | 2022-07-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-25 | 2022-03-16 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-01-05 | 2022-02-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-04-12 | 2021-04-14 | Y |
| Use approved construction type or materials. | Fire Safety | 2019-03-11 | 2019-05-14 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-03-11 | 2019-05-14 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2019-03-11 | 2019-05-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-03-11 | 2019-05-14 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-02-27 | 2019-03-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-02-27 | 2019-03-22 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2019-02-27 | 2019-03-22 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-02-27 | 2019-03-22 | N |
| Provide or obtain dental services for each resident. | Health | 2019-02-27 | 2019-03-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-02-27 | 2019-03-22 | N |
| Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. | Health | 2019-02-27 | Not Fixed | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-02-27 | Not Fixed | N |
