A list of the most recent deficiencies for Hillcrest Care Center. 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 voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-03-30 | 2023-04-27 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-03-30 | 2023-04-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-03-30 | 2023-04-27 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-03-30 | 2023-04-27 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-30 | 2023-04-27 | N |
| Keep all essential equipment working safely. | Health | 2023-03-30 | 2023-04-27 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-03-30 | 2023-04-27 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-03-30 | 2023-04-27 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2023-03-30 | 2023-04-27 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-03-30 | 2023-04-27 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-03-30 | 2023-04-27 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-03-30 | 2023-04-27 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-03-30 | 2023-04-27 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2023-03-30 | 2023-04-27 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-03-30 | 2023-04-27 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-03-30 | 2023-04-27 | N |
| Develop a communication plan. | Fire Safety | 2023-03-30 | 2023-04-27 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-03-30 | 2023-04-27 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-03-30 | 2023-04-27 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-03-30 | 2023-04-27 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-12-30 | 2022-01-29 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-12-30 | 2022-01-29 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-12-30 | 2022-01-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-12-30 | 2022-01-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-16 | 2022-01-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-16 | 2022-01-24 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-12-30 | 2022-01-24 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2021-12-16 | 2022-01-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-12-16 | 2022-01-12 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2021-12-16 | 2022-01-12 | 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 | 2021-12-16 | 2022-01-06 | N |
| Notify the appropriate authorities when residents with MD or ID services has a significant change in condition. | Health | 2021-12-16 | 2022-01-05 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2020-10-07 | 2020-11-05 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2020-10-07 | 2020-11-05 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2020-09-24 | 2020-10-20 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2020-09-24 | 2020-10-16 | N |
