Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Care Center during CMS and state inspections, most recent first.
The facility failed to ensure residents were offered hand hygiene before meals, as observed in the dining room and during room tray deliveries. Staff did not assist or encourage hand hygiene, and meal trays lacked sanitizing packets. Interviews with residents and staff confirmed the inconsistency in practice, despite the facility's policy and CDC guidelines emphasizing the importance of hand hygiene.
A resident with severe cognitive impairment and intellectual disabilities related to a congenital hypoxic brain injury did not receive a required Level II PASRR after a 30-day provisional admission. The facility's failure to complete this assessment in a timely manner was acknowledged by the SSD, NHA, and DON, who recognized its importance in providing recommendations to improve the resident's quality of life.
A resident with severe cognitive impairment and type 2 diabetes did not receive prescribed insulin consistently when their blood sugar levels exceeded 300 mg/dl. Over three months, the facility failed to administer the required insulin multiple times, despite clear physician orders. Interviews with the DON and NHA confirmed that the nursing staff did not consistently follow the orders or document the administration decisions.
A facility failed to provide appropriate care for a resident with a feeding tube, resulting in a deficiency. The resident, with a history of intracranial injury and dysphagia, had an active order for tube feedings that were not administered, and there was no documentation explaining the hold. Additionally, there was no active order to flush the feeding tube, which is necessary to prevent clogging. Staff interviews revealed a lack of awareness and documentation regarding the resident's feeding tube care.
The facility failed to maintain the kitchen, dish room, and serving areas according to professional standards, with issues such as torn flooring, debris, and chipped paint observed. Interviews revealed a lack of work orders for necessary repairs, despite regular cleaning schedules.
The facility failed to address grievances raised during resident council meetings, including issues like residents being left in the dining room for extended periods, lack of staff presence, inappropriate staff conversations, and delayed call light responses. Despite repeated concerns, there was no follow-up or resolution, and the grievance process was ineffective, as acknowledged by the NHA and DON.
Failure to Implement Hand Hygiene Before Meals
Penalty
Summary
The facility failed to maintain an effective infection control program, specifically in ensuring residents were offered hand hygiene before meals. Observations revealed that during meal times in the dining room, none of the 21 residents present were offered or assisted with hand hygiene. Staff members were observed providing clothing protectors but did not encourage or assist residents with hand hygiene, despite the facility's policy requiring such actions. Additionally, meal trays delivered to residents' rooms lacked individual hand sanitizing packets, and the dietary manager confirmed that hand hygiene was not encouraged or assisted during tray delivery. Interviews with residents and staff further highlighted the deficiency. Several residents reported that they were not offered hand hygiene before meals, with one resident noting that the practice of providing sanitizer bottles on dining tables had been discontinued months ago. Staff interviews corroborated these findings, with CNAs admitting they did not offer hand hygiene to residents who ate independently. The infection preventionist and the director of nursing both acknowledged the importance of hand hygiene in preventing infections and confirmed that residents should be offered hand hygiene prior to meals. The facility's infection preventionist and director of nursing recognized the lapse in practice, noting that the previous nursing home administrator had removed sanitizing wipes from room trays. Despite the facility's policy and the CDC's guidelines emphasizing the importance of hand hygiene before meals, the practice was not consistently implemented, leading to a deficiency in the infection control program.
Failure to Complete Level II PASRR for Resident
Penalty
Summary
The facility failed to ensure a Level II preadmission screening and resident review (PASRR) was completed for a resident, which is necessary for gaining and maintaining their highest practical medical, emotional, and psychosocial well-being. The resident, over the age of 65, was admitted with diagnoses including anxiety, chronic pain, and an unspecified mental disorder due to known psychological conditions. The resident's minimum data set (MDS) assessment indicated severe cognitive impairment. The initial PASRR Level I assessment was a 30-day hospice provisional admission, requiring a follow-up if the resident did not discharge as expected. However, the facility did not complete a necessary Level II PASRR after the provisional period expired. The social services director (SSD) acknowledged that the resident had intellectual disabilities related to a congenital hypoxic brain injury at birth and confirmed that a follow-up PASRR Level I should have been completed 30 days after the initial assessment. The SSD also noted that the PASRR Level II would provide recommendations to improve the resident's quality of life. Interviews with the nursing home administrator (NHA) and the director of nursing (DON) further emphasized the importance of the PASRR Level II in providing person-centered assessments and recommendations to meet the resident's needs. Despite these acknowledgments, the necessary PASRR Level II was not completed in a timely manner, leading to the deficiency noted in the report.
Failure to Administer Insulin as Prescribed
Penalty
Summary
The facility failed to administer insulin according to physician's orders for a resident with type 2 diabetes. The resident, who had severe cognitive impairment, was supposed to receive eight units of Humalog insulin when their blood sugar level exceeded 300 mg/dl. However, the facility did not consistently administer the insulin as needed, resulting in multiple instances where the resident's elevated blood sugar levels were not addressed according to the prescribed orders. In July 2024, the resident's blood sugar level exceeded 300 mg/dl fourteen times, but the prescribed insulin was only administered eight times. Similarly, in August 2024, the resident's blood sugar level was above 300 mg/dl ten times, yet the insulin was administered only five times. In September 2024, the resident's blood sugar level exceeded 300 mg/dl ten times, but the insulin was not administered at all during these instances. Interviews with the DON and NHA confirmed that the nursing staff did not consistently follow the physician's orders. The DON acknowledged that some nurses administered the insulin while others did not, and emphasized that the nursing staff should have followed the physician's orders or sought clarification if there was any confusion. The NHA also confirmed that the insulin should have been administered each time the resident's blood sugar level was above 300 mg/dl, and noted that there should have been documentation regarding the administration or non-administration of the insulin.
Failure to Ensure Proper Feeding Tube Care
Penalty
Summary
The facility failed to ensure that a resident with a feeding tube received appropriate treatment and services to prevent complications. Specifically, the facility did not update and maintain accurate physician's orders for the resident's feeding tube care. The resident, who had a history of intracranial injury, dysphagia, heart disease, and depression, was not receiving tube feedings as ordered, and there was no documentation explaining why the feedings were held. Additionally, the facility did not have an active order to flush the resident's feeding tube, which is necessary to maintain patency and prevent clogging. Interviews with staff revealed a lack of awareness and documentation regarding the resident's feeding tube care. A registered nurse admitted to flushing the tube without documenting it, and the medical director was unaware of the active tube feeding order. The director of nursing acknowledged that the feeding tube should have been flushed and documented, and the infection preventionist emphasized the importance of flushing to prevent infection. The facility's failure to ensure proper feeding tube care and documentation led to a deficiency in the resident's treatment.
Facility Fails to Maintain Kitchen and Serving Areas
Penalty
Summary
The facility failed to maintain the kitchen, dish room, and serving areas in accordance with professional standards for food service safety. Observations revealed multiple environmental concerns, including torn linoleum flooring, debris accumulation, unused wall anchors, lint in exhaust vents, chipped paint, and loose baseboards in the dish room. The kitchen had several small holes in the walls, sheetrock damage, bug remnants in a ceiling light fixture, stained metal screens, and debris behind the ice machine. The serving area was missing doors under the counter, had sheetrock damage, and debris along the base of the counter and in room corners. Interviews with the nursing home administrator (NHA) and maintenance supervisor (MS) indicated a lack of work orders for necessary repairs in these areas. The MS confirmed that the floors were cleaned daily and deep cleaned monthly, but no work orders had been placed for maintenance staff to address the identified issues. The NHA acknowledged the absence of work orders and stated that the floors and baseboards should be clean and free of debris.
Facility Fails to Address Resident Grievances
Penalty
Summary
The facility failed to address and act promptly upon grievances and recommendations made during resident council meetings, which were crucial to the residents' care and quality of life. The grievances included issues such as residents being left in the dining room for up to an hour after meals, lack of staff presence in the dining room, inappropriate staff conversations, rude staff members, and delayed call light response times. Despite these concerns being raised repeatedly in resident council meetings, the facility did not provide follow-up communication or resolution. Resident interviews revealed that the concerns were consistently brought up in resident council meetings without any resolution. A resident reported that staff would turn off call lights and promise to return but never did, and staff were often seen on their cell phones, not engaging with residents. The resident also mentioned that staff complained when residents requested something off the alternate menu, making them feel like an imposition. The facility's policy required prompt efforts to resolve grievances, but this was not adhered to, as evidenced by the lack of documented plans to assess, audit, monitor, or take further action on the grievances. Staff interviews corroborated the residents' concerns, with a frequent visitor noting that the same issues had been raised since the previous year without resolution. The NHA acknowledged the ineffective grievance process and the lack of a plan to address the residents' concerns. The DON admitted to not receiving education on responding to grievances and was unaware of the need to respond within 72 hours. The social service director expressed concern over the lack of acceptable responses and investigations into grievances, highlighting the facility's ineffective grievance process.
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 citations issued around you in the last 12 months — including the 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 Wray
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cheyenne County Village Inc | 29.9 mi | ★★★★★ | 5 | 0 |
| Sarah Ann Hester Memorial Home | 36 mi | ★★★★★ | 7 | 0 |
| Regent Park Care Center | 36.4 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Hillcrest Care Center.
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.