Deficiency Records for Hillcrest Manor Sanitarium
Updated as of June 01, 2023
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? |
---|---|---|---|---|
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 |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2020-08-18 | 2020-09-15 | 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 |
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 |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-01-11 | 2018-03-15 | N |
Respond appropriately to all alleged violations. | 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 |
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 |
Provide properly protected cooking facilities. | Fire Safety | 2018-02-08 | 2018-02-26 | N |
Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2018-02-08 | 2018-02-26 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-02-08 | 2018-02-26 | 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 |