Deficiency Records for Hillcrest Manor Sanitarium
Updated as of April 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 |
