Deficiency Records for Hillcrest Nursing and Rehabilitation Community
Updated as of March 01, 2024
A list of the most recent deficiencies for Hillcrest Nursing and Rehabilitation Community. 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 request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-10-03 | 2023-11-09 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-10-03 | 2023-11-09 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-03 | 2023-11-09 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-10-03 | 2023-11-09 | 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 | 2023-10-03 | 2023-11-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-03 | 2023-11-09 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-10-03 | 2023-11-09 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-10-03 | 2023-11-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-10-03 | 2023-11-09 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-05-05 | 2023-06-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-05 | 2023-06-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-05 | 2023-06-05 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-05-05 | 2023-06-05 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-31 | 2022-12-13 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-05 | 2022-12-13 | 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 | 2022-10-05 | 2022-12-13 | 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 | 2022-10-05 | 2022-12-13 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-10-05 | 2022-12-13 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-10-04 | 2022-11-08 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-10-04 | 2022-11-08 | 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 | 2022-10-04 | 2022-11-08 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-10-04 | 2022-11-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-07-13 | 2022-01-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-07-16 | 2021-10-22 | 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 | 2021-07-16 | 2021-10-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-16 | 2021-10-22 | 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 | 2021-07-16 | 2021-10-22 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-07-16 | 2021-10-22 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-07-16 | 2021-10-06 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-07-16 | 2021-10-06 | 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 | 2021-07-16 | 2021-10-06 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-07-16 | 2021-10-06 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-07-16 | 2021-10-06 | N |
| Respond appropriately to all alleged violations. | Health | 2021-07-16 | 2021-10-06 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-07-16 | 2021-10-06 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-07-16 | 2021-10-06 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-07-16 | 2021-10-06 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-07-16 | 2021-10-06 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2021-07-16 | 2021-10-06 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2021-07-16 | 2021-10-06 | 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 | 2021-07-16 | 2021-10-06 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-07-16 | 2021-10-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-07-16 | 2021-10-06 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2021-07-16 | 2021-10-06 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-07-13 | 2021-08-24 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2021-07-13 | 2021-08-24 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-07-13 | 2021-08-24 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-07-13 | 2021-08-24 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-07-13 | 2021-08-24 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-07-13 | 2021-08-24 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-07-13 | 2021-08-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-07-13 | 2021-08-24 | N |
