Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hillcrest Post Acute during CMS and state inspections, most recent first.
The facility did not properly implement infection prevention and control measures, including failing to remove a face shield after a resident was cleared from COVID-19 isolation and not providing required PPE outside the rooms of several residents on Enhanced Barrier Precautions. Staff confirmed these lapses, which were not in line with CDC guidelines or facility policy.
Three outside dumpsters near the kitchen were found uncovered and overflowing with garbage, producing a foul odor and attracting flies. The DM confirmed the dumpsters should have been covered and that maintenance was responsible for keeping them closed, in accordance with facility policy.
A resident room was found with a privacy curtain and ceiling vent visibly soiled with thick, dripping substances. Both the curtain and vent were confirmed dirty by staff, and the facility lacked a policy for cleaning vents. These conditions were present in a room with four medically fragile residents.
A CNA was employed without a completed background check, as required by facility policy. Review of the employee file and confirmation from HR revealed that the necessary screening was not conducted before the CNA began work, despite procedures mandating background checks prior to employment.
A resident was incorrectly coded in the MDS as having an active diagnosis of viral hepatitis, despite not receiving any treatment or medication for the condition. The resident had a history of Chronic Viral Hepatitis C, but review of medical records and staff interviews confirmed the diagnosis was not active and should not have been reported as such.
A resident requiring maximal assistance for bathing due to hemiplegia did not receive a shower or bed bath for 16 days, despite being scheduled for twice-weekly showers. The resident was observed with poor hygiene and expressed dissatisfaction with grooming frequency. There was no documentation of care refusals, and the DON confirmed the missed care.
A resident with a left-hand contracture and dementia, requiring total care, did not have a physician-ordered hand roll applied during multiple observations. Staff confirmed the hand roll should have been in place, but it was not, and the facility could not provide a policy for following physician orders.
Two residents experienced medication errors when a nurse administered an incorrect dosage of Baclofen to a resident with chronic pain syndrome and gave Metformin without food to another resident with type 2 diabetes, resulting in a medication error rate of 6%, above the acceptable threshold. Facility policy required confirmation of orders and adherence to administration instructions, which was not followed in these cases.
A resident's naloxone nasal spray with an expired date was found stored in a medication cart. During observation and interview, an LVN confirmed the medication should have been discarded, and the DON stated that expired medications are to be discarded per facility policy.
The facility failed to submit a timely report of an alleged elder abuse investigation to the State Survey Agency. The incident occurred, and the report was due within five days. The Administrator acknowledged the delay, citing personal business as the reason for not sending the report. As of the latest review, the report was still unavailable.
A facility failed to report an abuse incident involving a resident with Parkinson's Disease and other conditions, who experienced rough handling by an unlicensed staff member during a brief change. The staff member did not follow the policy requiring two staff for Hoyer Lift use, and the resident's repeated requests to stop were ignored. The administrator did not report the incident to authorities, citing the resident's alleged aggression, and was unaware of the staff member's history of rights violations.
A resident with a pressure ulcer was not given pain medication before treatment, despite having a physician's order for PRN pain relief. The resident requested medication, but Licensed Staff A proceeded with the treatment without assessing pain, causing discomfort. Interviews revealed that staff were expected to manage pain prior to treatment, but this was not done.
The facility did not post complete daily staffing information, missing the census, total staff numbers, and clear staff identification. The Administrator acknowledged these omissions during an interview.
The facility failed to designate a qualified Infection Preventionist (IP) after the resignation of the previous IP. Licensed Staff H and I filled in without proper credentials, with Staff I working 15 shifts as IP before obtaining certification. The facility lacked documentation of IP training and failed to comply with infection prevention policies, potentially exposing residents to infections.
The facility failed to provide two residents with vegetarian or no meat food preferences a list of planned vegetarian menu items to choose from. Despite having a vegetarian menu plan, the facility only distributed a regular menu without vegetarian alternatives. Both residents expressed dissatisfaction with the lack of choice, and the Dietary Manager and Registered Dietician acknowledged the oversight.
A resident with Parkinson's Disease and Diabetes Mellitus underwent left eye surgery, but the facility failed to monitor for post-surgical complications as required. Despite the surgery being a change of condition, there was no documentation of monitoring for signs of infection or discomfort, as confirmed by staff interviews and record reviews.
Two residents in the facility did not receive their prescribed ophthalmic medications on time, leading to potential health risks. One resident, post-eye surgery, experienced a three-day delay in receiving an antibiotic due to insurance issues, and the medication was not administered at the scheduled times. Another resident with glaucoma also faced delays in receiving eye medications. The facility's policy on medication administration was not followed, and the DON was unaware of the delivery issues.
The facility failed to address alleged verbal abuse incidents involving two residents by unlicensed staff. The DSD did not report these incidents to the ADM, who was the abuse coordinator, nor did she notify law enforcement or the State Agency. The ADM was unaware of the incidents, which were not discussed in management meetings, violating the facility's QAPI plan.
A facility failed to develop a person-centered care plan for a resident after left eye surgery, despite the facility's policy requiring care plans for changes in condition. Interviews with the DON and staff confirmed the oversight, which could lead to negative outcomes due to lack of communication and coordination among caregivers.
Expired COVID-19 vaccines and Arginaid were found in the facility's Medication Storage room and Medication Cart 1, violating the Medication Storage Policy. An LPN acknowledged the risks of administering expired medications, which could lead to ineffective vaccination and inadequate wound healing support.
A resident was prescribed Keflex indefinitely for a misdiagnosed facial rash, without proper tracking by the Infection Preventionist. The DON did not question the order, and the facility's policies on antibiotic stewardship were not followed, leading to the resident being on unnecessary antibiotics for 41 days.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to implement an effective infection prevention and control program as evidenced by improper handling and availability of personal protective equipment (PPE) for residents on isolation or enhanced barrier precautions. In one instance, a face shield was found hanging inside a resident's room after the resident had been cleared from COVID-19 isolation, with no labeling or dating, and no sign indicating isolation precautions. Staff interviews confirmed that the face shield should have been removed once isolation was discontinued, and its presence could have led to cross-contamination. Review of facility policy indicated that transmission-based precautions and associated PPE should be clearly identified and removed when no longer necessary. Additionally, seven residents on Enhanced Barrier Precautions (EBP) did not have PPE, such as gowns and gloves, available immediately outside their rooms, despite signage indicating EBP status. Observations and interviews with the Infection Preventionist, DON, and Administrator confirmed the absence of required PPE outside these rooms, which was not in accordance with CDC guidelines and facility policy. Facility documents and policies reviewed stated that PPE and alcohol-based hand rub should be readily accessible to staff when EBP is in place.
Uncovered and Overflowing Dumpsters Attracting Pests
Penalty
Summary
Three of four outside dumpsters located near the kitchen were observed to be uncovered and overflowing with garbage, emitting a foul odor and attracting many flies. This was directly observed during a walkthrough with the Dietary Manager (DM), who confirmed that the dumpsters should have been covered. The DM stated that the maintenance department was responsible for ensuring the dumpsters were maintained and closed, and acknowledged that dumpsters needed to remain closed to prevent attracting pests that could lead to food contamination. A review of the facility's policy and procedure on food-related garbage and refuse disposal indicated that outside dumpsters provided by garbage pickup services were to be kept closed and free of surrounding litter.
Failure to Maintain Sanitary and Homelike Resident Room Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a sanitary and comfortable environment in one of the resident rooms. Specifically, Bed A's privacy curtain was visibly soiled with a thick black substance dripping down in numerous areas. Both the Maintenance Assistant and the Administrator confirmed the curtain was dirty and acknowledged it should have been changed. The facility's policy on cleaning and repairing cloth furnishings indicated that such items should be cleaned regularly and repaired promptly, but this was not followed in this instance. Additionally, the ceiling vent above Bed C in the same room had a visible accumulation of a thick brown dripping substance. The Maintenance Assistant confirmed the vent was dirty and needed cleaning, and the Administrator agreed after viewing the vent. The facility did not provide a policy or procedure for cleaning vents in resident rooms. These deficiencies were observed in a room housing four medically fragile residents, potentially exposing them to unsanitary conditions.
Failure to Complete Required Background Check Prior to CNA Employment
Penalty
Summary
The facility failed to ensure that one of five Certified Nursing Assistants (CNA) underwent a background check prior to employment. During an interview and review of employee records, it was found that the CNA's file was missing documentation of a completed background check. The Administrator confirmed with Human Resources that the background check had not been conducted, despite the facility's policy requiring all employees to complete background screening, reference checks, and criminal conviction investigations before beginning employment. The policy specified that these checks should be initiated within two days of an employment offer and completed prior to the start of work. This lapse was identified during a review of the employee file and confirmed by facility leadership.
Inaccurate MDS Coding of Active Diagnosis
Penalty
Summary
The facility failed to accurately assess and submit data for one resident when the Minimum Data Set (MDS) did not reflect the resident's current status. Specifically, the MDS 3.0 Section I- Active Diagnoses listed an active diagnosis of viral hepatitis for a resident who had a history of Chronic Viral Hepatitis C but was not receiving any treatment or medication for this condition. Review of the resident's active orders confirmed there was no treatment in place for viral hepatitis. The MDS Coordinator acknowledged that the resident was admitted with a previous diagnosis but had not received any related treatment, and the Administrator confirmed that the diagnosis should not have been coded as active. According to the CMS LTCF RAI 3.0 User's Manual, only diagnoses with a direct relationship to the resident's current status or treatment should be coded as active.
Failure to Provide Scheduled Showers or Bed Baths
Penalty
Summary
A resident with hemiplegia following a cerebral infarction, resulting in loss of movement on the right side of the body, was admitted to the facility and required maximal assistance for showering and bathing, as documented in the Minimum Data Set (MDS). Despite being scheduled for showers twice weekly, records showed that the resident did not receive a shower or bed bath for a period of 16 days. There was no documentation indicating that the resident refused care during this time. During an observation, the resident was noted to have an accumulation of dirt under her fingernails and dry, flaky skin on her right hand. The resident reported only receiving a couple of bed baths in the past month and expressed dissatisfaction with the frequency of grooming, stating a desire to be groomed more often. The Director of Nursing confirmed the lack of documentation for refusals and acknowledged that the resident should have received four showers or bed baths during the 16-day period, as per the facility's schedule and policy.
Failure to Apply Prescribed Hand Roll for Resident with Contracture
Penalty
Summary
A resident with a diagnosis of left-hand contracture and dementia was admitted to the facility and required total assistance with all activities of daily living due to limited mobility and cognitive impairment. The resident's care plan and physician order specified the use of a hand roll in the left hand each morning, to be removed at night, as a preventative measure against worsening contracture. Multiple observations over two days revealed that the resident was seated in a Geri-chair with the left wrist bent downward and without a hand roll, brace, or splint in place as ordered. Interviews with facility staff, including the Infection Preventionist, Director of Nursing, and Director of Rehabilitation, confirmed that the hand roll should have been applied according to the physician's order. The facility was unable to provide a policy or procedure for following physician orders. The failure to apply the prescribed hand roll as ordered constituted a deficiency in care for the resident with a left-hand contracture.
Medication Error Rate Exceeds Acceptable Threshold Due to Incorrect Dosage and Timing
Penalty
Summary
The facility failed to ensure that the medication error rate remained below 5 percent, as evidenced by two medication errors out of 30 observed opportunities, resulting in a 6 percent error rate. In the first instance, a licensed vocational nurse administered only 10 mg of Baclofen to a resident with chronic pain syndrome, despite a physician order for 15 mg three times daily. The nurse acknowledged the error, confirming that only one tablet was given instead of the required one and a half tablets, and the facility's policy required confirmation of medication orders prior to administration. In the second instance, another resident with type 2 diabetes was administered Metformin 500 mg without breakfast, contrary to the physician's order specifying administration with breakfast and dinner. The nurse confirmed that the medication was not given within the appropriate time frame relative to the meal, and the facility's policy required medications with specific administration instructions to be given according to manufacturer recommendations. The pharmacist also confirmed that Metformin should be administered with food to prevent gastrointestinal discomfort.
Expired Medication Not Discarded
Penalty
Summary
A deficiency occurred when a resident's naloxone nasal spray, which had an expiration date of July 2025, was found stored in a medication cart. During an observation and interview, a Licensed Vocational Nurse acknowledged that the naloxone should have been discarded. The Director of Nursing also confirmed in an interview that all expired medications should be discarded. The facility's policy and procedure on medication labeling and storage indicated that discontinued, outdated, or deteriorated medications or biologicals require the dispensing pharmacy to be contacted for instructions on returning or destroying these items. The failure to discard the expired naloxone was identified through observation, interview, and record review.
Failure to Submit Timely Abuse Investigation Report
Penalty
Summary
The facility failed to provide a report of the results of their investigations to the State Survey Agency within 5 working days of an alleged elder abuse incident. The alleged incident occurred on 3/14/25, and the report was due within five days. During an interview on 3/17/25, the Administrator acknowledged that the 5-day report was in process and needed to be completed and sent to the department soon. However, by 3/24/25, the report was still not available, and the Department had to request a copy via email. The Administrator admitted to being busy with personal business and forgetting to send the report. As of 3/27/25, the report was still not available in the facility's records.
Failure to Report Abuse and Protect Resident Rights
Penalty
Summary
The facility failed to adhere to its Abuse Reporting Policy when the administrator did not report an incident of alleged abuse within the required 24-hour period to the state licensing agency and local authorities. This incident involved a resident, who was not informed that the unlicensed staff member involved would be suspended during the investigation. The resident, who has a history of Parkinson's Disease, Polymyalgia Rheumatica, and other conditions, reported that the unlicensed staff member was rough during a brief change, causing significant discomfort. The incident occurred when the unlicensed staff member attempted to use a Hoyer Lift without assistance, contrary to the facility's policy requiring two staff members for such procedures. The resident repeatedly asked the staff member to stop pushing on her back due to pain, but the staff member did not comply. The resident eventually pushed the staff member's arm away, leading to an altercation. The resident expressed feeling unsafe and not wanting the staff member to care for her again, citing previous instances of rudeness and neglect. The facility's investigation into the incident was inadequate, as the administrator was unaware of the staff member's history of resident rights violations and did not conduct a thorough investigation. The administrator also failed to report the incident to the appropriate authorities, believing it was unnecessary since the resident allegedly hit the staff member. This oversight resulted in a lack of protection for the resident's rights and a delay in addressing the resident's concerns and pain management needs.
Failure to Administer Pain Medication Before Pressure Ulcer Treatment
Penalty
Summary
The facility failed to provide adequate pain management for a resident, identified as Resident 47, who was undergoing treatment for a pressure ulcer. Despite having a physician's order for pain medications, including Acetaminophen and Oxycodone, to be administered as needed for varying levels of pain, the resident was not given pain medication prior to the pressure ulcer treatment. During an observation, Resident 47 requested pain medication from Licensed Staff A before the treatment began, but was informed that it was not due until later. Licensed Staff A proceeded with the treatment without assessing the resident's pain level or administering the medication, resulting in the resident experiencing pain and discomfort during the procedure. Interviews with staff, including Licensed Staff A and the Director of Nursing (DON), revealed that there was an expectation for nurses to assess and manage pain prior to wound treatment. Licensed Staff A admitted to not administering pain medication before the treatment, despite acknowledging that pain could worsen during such procedures. The DON confirmed that pain management should be prioritized and that the resident had orders for PRN pain medications. The facility's policy on pain assessment and management emphasized the importance of appropriate pain assessment and treatment, which was not adhered to in this instance.
Deficiency in Daily Staffing Information Posting
Penalty
Summary
The facility failed to ensure that the posted daily staffing schedule included all required information. Specifically, the schedule lacked the census, which is the number of residents in the facility, and the total numbers of licensed and unlicensed staff. Additionally, the schedule did not reflect staff absences due to call-outs and illness, nor did it clearly identify staff names in a readable format, as it only included first names without last names or initials. This deficiency was identified during an observation and interview with the Administrator, who acknowledged the absence of the required information and the issue with staff name identification.
Failure to Designate Qualified Infection Preventionist
Penalty
Summary
The facility failed to designate a fully credentialed Infection Preventionist (IP) responsible for the infection prevention and control program. The Director of Nursing (DON) was unable to identify a current IP after the resignation of the previous IP, Licensed Staff H, on December 29, 2023. Since then, both Licensed Staff H and Licensed Staff I have been filling in, but neither was consistently signed in as the IP on staffing sheets. Licensed Staff H had limited workdays and was not signed in as the IP on any of those days. Licensed Staff I worked as the IP for 15 shifts without the necessary certification until March 1, 2024, which was 2.5 months after Licensed Staff H's resignation. The facility's policies and procedures require that the IP and DON receive ongoing training on the facility's antibiotic stewardship program and infection prevention and control responsibilities. However, there was no evidence of a policy for the IP role, and the facility failed to provide documentation of the IP's primary professional training and specialized training in infection prevention and control. The facility's governing board is responsible for oversight of facility care and services, including infection prevention and control, but there was no evidence of compliance with these responsibilities. The facility's failure to maintain a qualified IP and adhere to infection prevention and control policies potentially exposed residents to infections and unnecessary medications. The facility's assessment and administrative management policies emphasize the importance of aligning resources with resident needs, but the lack of a qualified IP indicates a misalignment in infection control resources. The DON's job description includes ensuring compliance with infection prevention procedures, but the absence of a designated IP suggests a gap in fulfilling this responsibility.
Failure to Provide Vegetarian Menu Options
Penalty
Summary
The facility failed to provide residents with vegetarian or no meat food preferences a list of planned vegetarian menu items to choose from, affecting two residents. Resident 19, a vegetarian, reported that the meals were repetitive and lacked variety, and she was not provided with a list of vegetarian menu options. Her diet order indicated a vegetarian meal plan, but she received the same menu as other residents without vegetarian alternatives. Similarly, Resident 158, who only eats fish and vegetables, did not receive a menu with vegetarian options, expressing a desire for more choice in her meals. The facility had two separate weekly menus, one with vegetarian options and one without, but only the latter was distributed to residents. The Dietary Manager acknowledged having a vegetarian menu plan but stopped providing it to residents. The Registered Dietician confirmed that the menus were reviewed monthly and agreed that the vegetarian options should have been included to offer residents a choice. The facility's policy stated that individual food preferences should be identified and incorporated into meal plans, but this was not followed, leading to the deficiency.
Failure to Monitor Post-Surgical Complications
Penalty
Summary
The facility failed to assess and monitor for signs of complications following a surgical procedure for one resident. Resident 20, who had a history of Parkinson's Disease and Diabetes Mellitus, underwent left eye surgery for the removal and retention of silicone oil used in retinal detachment repair. Despite the surgery being considered a change of condition, there was no documentation indicating that the resident was assessed or monitored for signs of complications such as eye infection or discomfort. Interviews with facility staff revealed that the expected protocol was to monitor the resident for complications every shift for 72 hours post-surgery and document these observations. However, a review of the nurses' progress notes from the period following the surgery showed no evidence of such monitoring or documentation. This lack of action and documentation was confirmed by both Licensed Staff D and the Director of Nursing, indicating a failure to adhere to the facility's policy on monitoring acute condition changes.
Failure to Administer Ophthalmic Medications Timely
Penalty
Summary
The facility failed to administer ophthalmic medications according to the doctor's orders for two residents, leading to potential health risks. Resident 20, who had undergone left eye surgery, did not receive the prescribed Ofloxacin Ophthalmic Solution 0.3% for three days after the order was placed. The medication was delayed due to issues with the resident's medical insurance, and the facility did not notify the physician about the delay. Additionally, the medication was not administered at the scheduled times, with significant delays noted in the administration record. Resident 41, diagnosed with glaucoma, also experienced delays in receiving his prescribed eye medications. The medications were consistently administered hours after the scheduled times, which could potentially affect the resident's eye health. Interviews with the residents and staff revealed that the facility's policy allowed for a one-hour window before and after the scheduled time for medication administration, but this policy was not adhered to in these cases. The Director of Nursing was unaware of the medication delivery issues and stated that antibiotics should be administered within four hours of being ordered. The facility's policy on medication administration was not followed, as evidenced by the delayed administration and lack of documentation for the reasons behind the delays. These deficiencies highlight a failure in the facility's pharmaceutical services to meet the needs of the residents, potentially compromising their health and well-being.
Failure to Report and Address Alleged Verbal Abuse Incidents
Penalty
Summary
The facility failed to ensure that two residents, Resident 9 and Resident 19, received appropriate action and feedback regarding incidents of alleged verbal abuse by unlicensed staff. The Director of Staff Development (DSD) did not report an incident involving Resident 9, where an Ombudsman reported that Unlicensed Staff L was verbally abusive and mocking the resident. The DSD filled out an employee warning form but did not inform the Administrator (ADM), who was the abuse coordinator, nor did she notify law enforcement or the State Agency as required. In another incident, Resident 19 attempted to report verbal abuse by Unlicensed Staff M and N to the DSD. The resident stated that the staff scolded her, causing distress, and although she informed the DSD, she did not receive any follow-up. The DSD acknowledged that Resident 19 wanted to speak to her but admitted she did not return to the resident's room or inform the ADM or other management about the complaint. The ADM, who was responsible for investigating abuse allegations, was unaware of both incidents involving Residents 9 and 19. The ADM stated that abuse allegations should be discussed in daily management meetings, but these incidents were not reported or discussed. The facility's QAPI plan requires systematic investigations and communication of such issues, but these processes were not followed, leading to a failure in addressing and resolving the residents' complaints effectively.
Failure to Implement Post-Surgery Care Plan
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for Resident 20 following their left eye surgery. Resident 20, who was admitted with diagnoses including Parkinson's Disease and Diabetes Mellitus, underwent a procedure for the removal and retention of silicone oil used in retinal detachment repair. Despite the change in condition due to the surgery, no care plan was initiated to address the specific care needs post-surgery. Interviews with the Director of Nursing (DON) and Licensed Staff D revealed that the facility's policy required nurses to initiate a care plan when a resident experiences a change in condition. The DON confirmed that the Interdisciplinary Team, including herself, was responsible for reviewing and ensuring the care plan was in place. However, upon reviewing Resident 20's electronic record, it was found that no such care plan was developed. This lack of communication and coordination among caregivers could potentially lead to negative outcomes for the resident.
Expired Medications Found in Storage and Cart
Penalty
Summary
The facility failed to adhere to its Medication Storage Policy, resulting in the presence of expired medications in the Medication Storage room and Medication Cart 1. Specifically, three expired COVID-19 vaccines and two boxes of expired Arginaid, a wound healing nutrition supplement, were found. These expired items were discovered during observations conducted by surveyors. The expired COVID-19 vaccines were located in the medication refrigerator, while the expired Arginaid was found both in the Medication Storage room and on Medication Cart 1. Licensed Staff C, when interviewed, acknowledged the potential risks associated with administering expired medications. She indicated that an expired COVID-19 vaccine might not effectively vaccinate a resident due to the deterioration of the medication. Similarly, she expressed concerns that expired Arginaid would not support wound healing, potentially leading to worsening of the wound. The facility's policy, dated 2007, mandates the immediate removal and proper disposal of outdated, contaminated, or deteriorated medications, which was not followed in this instance.
Failure in Antibiotic Stewardship and Monitoring
Penalty
Summary
The facility failed to adhere to its Antibiotic Stewardship Clinician Roles Policy when a resident was prescribed Keflex, an antibiotic, indefinitely without proper tracking and surveillance by the Infection Preventionist. The resident was started on Keflex 500 mg twice daily for a supposed facial rash, which was not documented or observed during the survey. The resident, who had a BIMS score of 12 out of 15, was unaware of the reason for the antibiotic prescription. The Director of Nursing (DON) did not question the indefinite order, citing the doctor's authority, and was unsure of the facility's Antibiotic Stewardship Policy regarding start and stop dates. The medical records revealed that the resident's care plan and nurses' notes consistently mentioned the antibiotic was for a facial rash, despite no physical assessment or documentation supporting this diagnosis. The DON later discovered that the diagnosis of a facial rash was incorrect and that the antibiotic was actually prescribed for osteomyelitis of the left hip. This miscommunication and lack of proper documentation and oversight led to the resident being on an unnecessary antibiotic regimen for 41 days. The facility's policies and procedures, including the Antibiotic Stewardship Program, require staff to be trained on appropriate prescribing, monitoring, and surveillance of antibiotic use. However, the DON admitted to not being aware of the national standards the facility follows and had been filling in for the Infection Preventionist since their departure in December 2023. This lack of adherence to established protocols and insufficient oversight contributed to the deficiency in antibiotic stewardship at the facility.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 552 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Petaluma
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Petaluma Post-acute Rehabilitation | 0 mi | ★★★★★ | 9 | 0 |
| Ridgeway Post Acute | 0.1 mi | ★★★★★ | 2 | 0 |
| North Bay Post Acute | 0.6 mi | ★★★★★ | 24 | 0 |
| Vineyard Post Acute | 2.5 mi | ★★★★★ | 28 | 0 |
| Novato Healthcare Center | 9.6 mi | ★★★★★ | 44 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Hillcrest Post Acute.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.