A list of the most recent deficiencies for Hillcrest Nursing Home. 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-05-02 | 2023-05-08 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-03-03 | 2022-04-14 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-03-03 | 2022-04-14 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-03-03 | 2022-04-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-03-03 | 2022-04-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-03-03 | 2022-04-14 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-03-03 | 2022-04-14 | 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 | 2022-03-03 | 2022-04-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-03 | 2022-04-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-03 | 2022-04-14 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2022-03-03 | 2022-04-14 | N |
| Have policies on smoking. | Health | 2022-03-03 | 2022-04-14 | N |
| Provide emergency officials' contact information. | Fire Safety | 2022-03-10 | 2022-03-28 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2022-03-10 | 2022-03-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-03-10 | 2022-03-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-10 | 2022-03-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-03-10 | 2022-03-28 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-03-10 | 2022-03-28 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2022-03-10 | 2022-03-28 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-10-30 | 2019-11-19 | N |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2019-10-30 | 2019-11-19 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-10-30 | 2019-11-19 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2019-10-30 | 2019-11-19 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2019-10-30 | 2019-11-19 | N |
| Provide emergency officials' contact information. | Fire Safety | 2019-10-30 | 2019-11-19 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-10-30 | 2019-11-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-30 | 2019-11-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-10-30 | 2019-11-19 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-10-04 | 2019-10-30 | 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 | 2019-10-04 | 2019-10-30 | 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 | 2019-10-04 | 2019-10-30 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2019-10-04 | 2019-10-30 | 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 | 2019-10-04 | 2019-10-30 | N |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2019-10-04 | 2019-10-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-10-04 | 2019-10-30 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2019-10-04 | 2019-10-30 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-10-04 | 2019-10-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-04 | 2019-10-30 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-10-04 | 2019-10-30 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-10-04 | 2019-10-30 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2018-12-04 | 2019-01-02 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2018-12-04 | 2019-01-02 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2018-12-04 | 2019-01-02 | N |
| Establish emergency prep training and testing. | Fire Safety | 2018-12-04 | 2019-01-02 | N |
| Use approved construction type or materials. | Fire Safety | 2018-12-04 | 2019-01-02 | 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 | 2018-12-04 | 2019-01-02 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2018-12-04 | 2019-01-02 | 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 | 2018-12-04 | 2019-01-02 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-12-04 | 2019-01-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-12-04 | 2019-01-02 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-12-04 | 2019-01-02 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2018-12-04 | 2019-01-02 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2018-12-04 | 2019-01-02 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-12-04 | 2019-01-02 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-12-04 | 2019-01-02 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-10-05 | 2018-10-31 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2018-10-05 | 2018-10-31 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2018-10-05 | 2018-10-31 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2018-10-05 | 2018-10-31 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2018-10-05 | 2018-10-31 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-10-05 | 2018-10-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-10-05 | 2018-10-31 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-10-05 | 2018-10-31 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2018-10-05 | 2018-10-31 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-10-05 | 2018-10-31 | 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 | 2018-10-05 | 2018-10-31 | 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 | 2018-10-05 | 2018-10-31 | 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 | 2018-10-05 | 2018-10-31 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-10-05 | 2018-10-31 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2018-10-05 | 2018-10-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-10-05 | 2018-10-31 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2018-10-05 | 2018-10-31 | N |
| Keep all essential equipment working safely. | Health | 2018-10-05 | 2018-10-31 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2018-10-05 | 2018-10-31 | N |
