Deficiency Records for Hillcrest Manor Sanitarium
Updated as of January 01, 2019
This is not the most recent data for Hillcrest Manor Sanitarium. For the most recent information, click here.
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 manage his or her financial affairs. | Health | 2018-01-11 | 2018-03-15 | 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 | 2018-01-11 | 2018-03-15 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-01-11 | 2018-03-15 | N |
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2018-01-11 | 2018-03-15 | N |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-01-11 | 2018-03-15 | N |
Provide enough food/fluids to maintain a resident's health. | Health | 2018-01-11 | 2018-03-15 | N |
Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-01-11 | 2018-03-15 | N |
Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-01-11 | 2018-03-15 | N |
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2018-01-11 | 2018-03-15 | N |
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2018-01-11 | 2018-03-15 | N |
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2018-01-11 | 2018-03-15 | N |
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-01-11 | 2018-03-15 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-01-11 | 2018-03-15 | N |
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2018-01-11 | 2018-03-15 | N |
Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2018-01-11 | 2018-03-15 | N |
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-01-11 | 2018-03-15 | 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 | 2018-01-11 | 2018-03-15 | N |
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2018-01-11 | 2018-03-15 | N |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-01-11 | 2018-03-15 | N |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-01-11 | 2018-03-15 | Y |
Respond appropriately to all alleged violations. | Health | 2018-01-11 | 2018-03-15 | Y |
Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-02-08 | 2018-02-26 | N |
Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-02-08 | 2018-02-26 | N |
Develop a communication plan. | Fire Safety | 2018-02-08 | 2018-02-26 | N |
Establish emergency prep training and testing. | Fire Safety | 2018-02-08 | 2018-02-26 | N |
Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2016-12-01 | 2017-01-05 | N |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2016-12-01 | 2017-01-05 | N |
Maintain 15 months of resident assessments in the resident's active clinical record. | Health | 2016-12-01 | 2017-01-05 | N |
Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2016-12-01 | 2017-01-05 | N |
Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-12-01 | 2017-01-05 | N |
Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2016-12-01 | 2017-01-05 | N |
Hire sufficient dietary support personnel. | Health | 2016-12-01 | 2017-01-05 | N |
Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2016-12-01 | 2017-01-05 | N |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2016-12-01 | 2017-01-05 | N |
Keep complete, dated laboratory records in the resident's file. | Health | 2016-12-01 | 2017-01-05 | N |
Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. | Health | 2016-12-01 | 2017-01-05 | N |
Proper backup exit lighting. | Fire Safety | 2016-01-27 | 2016-03-09 | N |
Record of quarterly fire drills for each shift under varying conditions. | Fire Safety | 2016-01-27 | 2016-03-09 | N |
Heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2016-01-27 | 2016-03-09 | N |
Weekly inspections and monthly testing of generators. | Fire Safety | 2016-01-27 | 2016-03-09 | N |
Provide bedrooms that hold no more than 4 residents per room. | Health | 2016-01-21 | 2016-02-17 | N |
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2016-01-21 | 2016-02-17 | N |
Employ staff that are licensed, certified, or registered in accordance with state laws. | Health | 2016-01-21 | 2016-02-17 | N |
Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2016-01-21 | 2016-02-17 | N |
Train all employees on what to do in an emergency, and carry out unannounced staff drills. | Health | 2016-01-21 | 2016-02-17 | N |
Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2016-01-21 | 2016-02-16 | N |
Have a program that investigates, controls and keeps infection from spreading. | Health | 2016-01-21 | 2016-02-12 | N |
Provide or obtain laboratory services only when ordered by the attending physician. | Health | 2016-01-21 | 2016-02-10 | N |
Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2016-01-21 | 2016-02-05 | N |
Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. | Health | 2016-01-21 | 2016-02-03 | N |
Store, cook, and serve food in a safe and clean way. | Health | 2016-01-21 | 2016-02-03 | N |
Ensure residents maintain acceptable nutritional status. | Health | 2016-01-21 | 2016-02-01 | N |
Provide bedrooms that hold no more than 4 residents per room. | Health | 2016-12-01 | 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 | 2016-12-01 | Not Fixed | N |