Deficiency Records for Hillcrest Commons Nursing and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Hillcrest Commons Nursing and Rehabilitation 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? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-08-22 | 2023-08-22 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-07-19 | 2023-08-16 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-07-19 | 2023-08-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-06-07 | 2023-07-07 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-06-07 | 2023-07-07 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-06-07 | 2023-07-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-27 | 2022-08-08 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-06-14 | 2022-07-22 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2022-06-14 | 2022-07-22 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-06-14 | 2022-07-22 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-06-14 | 2022-07-22 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-06-14 | 2022-07-22 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-06-14 | 2022-07-22 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-06-14 | 2022-07-22 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-06-14 | 2022-07-22 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-14 | 2022-07-22 | 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 | 2022-06-14 | 2022-07-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-14 | 2022-07-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-14 | 2022-07-22 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-06-14 | 2022-07-22 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-06-14 | 2022-07-22 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-06-14 | 2022-07-22 | 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 | 2022-06-14 | 2022-07-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-14 | 2022-07-22 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-06-14 | 2022-07-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-14 | 2022-07-22 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-06-14 | 2022-07-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-27 | 2022-03-07 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-12-29 | 2022-02-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-29 | 2022-02-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-29 | 2022-02-08 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-12-29 | 2022-02-08 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-08-26 | 2021-08-11 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-26 | 2021-08-11 | Y |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2021-07-08 | 2021-08-09 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-07-08 | 2021-08-09 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2021-07-08 | 2021-08-09 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2021-07-08 | 2021-08-09 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-07-08 | 2021-08-09 | 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 | 2021-07-08 | 2021-08-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-05-11 | 2021-06-03 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-11 | 2021-06-03 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-05-11 | 2021-06-03 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-05-11 | 2021-06-03 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-05-11 | 2021-06-03 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-05-11 | 2021-06-03 | Y |
| 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 | 2021-05-11 | 2021-06-03 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-05-11 | 2021-06-03 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-05-11 | 2021-06-03 | Y |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-12-18 | 2020-01-03 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2019-12-18 | 2020-01-03 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-10-18 | 2019-12-01 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-10-18 | 2019-12-01 | N |
| Assess the resident when there is a significant change in condition | Health | 2019-10-18 | 2019-12-01 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-10-18 | 2019-12-01 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-10-18 | 2019-12-01 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-10-18 | 2019-12-01 | 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 | 2019-10-18 | 2019-12-01 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-10-18 | 2019-12-01 | N |
| Provide activities to meet all resident's needs. | Health | 2019-10-18 | 2019-12-01 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2019-10-18 | 2019-12-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-10-18 | 2019-12-01 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-10-18 | 2019-12-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-10-18 | 2019-12-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-10-18 | 2019-12-01 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-10-18 | 2019-12-01 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-10-18 | 2019-12-01 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-10-18 | 2019-12-01 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-10-18 | 2019-12-01 | N |
| Provide or obtain dental services for each resident. | Health | 2019-10-18 | 2019-12-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-10-18 | 2019-12-01 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-18 | 2019-12-01 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-10-18 | 2019-12-01 | N |
