A list of the most recent deficiencies for Hillcrest Post Acute. 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? |
|---|---|---|---|---|
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-30 | 2023-04-17 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2023-01-12 | 2023-01-14 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-03-04 | 2022-04-19 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-03-04 | 2022-04-19 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-03-04 | 2022-04-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-04 | 2022-04-19 | 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 | 2022-03-04 | 2022-04-19 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-03-04 | 2022-04-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-04 | 2022-04-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-04 | 2022-04-19 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-03-04 | 2022-04-19 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-03-04 | 2022-04-19 | 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 | 2022-03-04 | 2022-04-19 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-03-04 | 2022-04-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-04 | 2022-04-19 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-03-17 | 2022-04-05 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-03-17 | 2022-04-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-03-17 | 2022-04-05 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-03-17 | 2022-04-05 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-01-06 | 2022-02-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-09-14 | 2021-10-21 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-04-30 | 2019-07-24 | 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 | 2019-04-30 | 2019-07-24 | 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 | 2019-04-30 | 2019-07-24 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-04-30 | 2019-07-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-04-30 | 2019-07-24 | N |
| Provide activities to meet all resident's needs. | Health | 2019-04-30 | 2019-07-24 | 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 | 2019-04-30 | 2019-07-24 | 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 | 2019-04-30 | 2019-07-24 | 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 | 2019-04-30 | 2019-07-24 | 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 | 2019-04-30 | 2019-07-24 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2019-04-30 | 2019-07-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-30 | 2019-07-24 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-04-30 | 2019-07-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-04-30 | 2019-07-24 | N |
| Keep all essential equipment working safely. | Health | 2019-04-30 | 2019-07-24 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2019-04-30 | 2019-07-24 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2019-06-27 | 2019-07-19 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-06-27 | 2019-07-19 | 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 | 2019-06-27 | 2019-07-19 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-06-27 | 2019-07-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-06-27 | 2019-07-19 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2018-05-23 | 2018-06-12 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-05-23 | 2018-06-12 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2018-05-23 | 2018-06-12 | N |
| Implement emergency and standby power systems. | Fire Safety | 2018-05-23 | 2018-06-12 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-05-23 | 2018-06-12 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-05-23 | 2018-06-12 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2018-05-23 | 2018-06-12 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-05-23 | 2018-06-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-05-23 | 2018-06-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-05-23 | 2018-06-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-05-23 | 2018-06-12 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-04-16 | 2018-05-24 | N |
