Average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hillcrest Home during CMS and state inspections, most recent first.
Medications Left Undated After Opening: The facility failed to ensure multiple open medications were dated for several residents. Observation of the med cart showed open bottles and an inhaler without open dates, and an LPN stated nurses were supposed to complete the date opened, expiration date, and initials on pharmacy stickers when medications were opened. The DON confirmed that nurses were expected to place an open date on each medication when it was initially opened.
Missing controlled medications and incomplete narcotic counts: Two residents had opioid medications missing from the narcotic drawer, including a hydromorphone bubble pack and a hydrocodone bubble pack, with related count sheets also missing. Staff interviews and narcotic logs showed shift-to-shift counts were not consistently completed or signed by both nurses, and staff reported that narcotic counts were often not done when carts changed possession. One resident had severe cognitive impairment and chronic pain, and the other had moderate cognitive impairment with acute pain related to fractures and dislocation.
Delayed response to activated call lights was identified for a resident with intact cognition who required assistance with toileting, transfers, and ambulation and had care plan interventions for impaired mobility, safety, weakness from TIA, and fall risk. The resident reported staff often shut off the call light without providing help, and alarm records showed multiple response times over 15 minutes, including several lasting more than 30 minutes and up to nearly an hour. Staff and the DON acknowledged that response times had exceeded the expected timeframe, and the facility policy required staff to respond to engaged call lights in a timely manner.
Failure to Complete SCSA MDS After Hospice Discharge: A resident who had been admitted on hospice and later discharged because the resident was no longer terminally ill did not have the required SCSA MDS completed after hospice ended. The EHR showed the change in payer status, and the HIM, MDS Coordinator, and DON all acknowledged the assessment was required and was not completed.
Failure to submit a PASRR update after a new PTSD dx. A resident with severe cognitive impairment and existing MH dxs had a prior PASRR Level I screen before admission, then later received new visit dxs of GAD, psychosis, and PTSD with new med orders. Social Services confirmed PASRR updates were her responsibility and acknowledged the new PTSD dx required an updated PASRR, and the Administrator agreed an updated PASRR should have been submitted.
Care plans for two residents did not include high risk medications identified in the MDS and physician orders. One resident with moderate cognitive impairment, heart failure, osteoporosis, and a limited prognosis had orders for tramadol, furosemide, and apixaban, while another resident with intact cognition, polyneuropathy, restless legs syndrome, and diabetes had orders for hydrocodone-acetaminophen; neither care plan addressed these opioid, diuretic, or anticoagulant therapies.
A resident with severely impaired cognition, dementia, depression, and heart failure was identified as an elopement risk and wore a wander alert on the ankle. Staff interviews and binder review showed the daily wander guard function checks were not consistently completed or documented, with missing sheets and multiple missed sign-offs, and the DON acknowledged the checks were not being done correctly.
Failure to provide trauma-informed care for a resident with PTSD, anxiety, depression, and psychotic disorder. The resident had severe cognitive impairment and exhibited anxiety, restlessness, delusions, hallucinations, and other behaviors, including calling 911 and pulling at her tube feed. Although telehealth resulted in new orders for mirtazapine and lorazepam, the care plan did not address the resident’s mental health diagnoses, triggers, goals, or interventions, and staff interviews showed limited knowledge of PTSD-related triggers and interventions. The DON acknowledged trauma assessments were due quarterly but had not been completed.
A resident's completed MDS assessments were not submitted to CMS as required, due to incorrect documentation of unit certification status and a lapse during a transition in MDS Coordinator staffing. The DON confirmed the omission, despite the facility being dually certified and required to submit these assessments.
A resident with severe cognitive impairment and a history of falls experienced an unwitnessed fall resulting in a hip fracture. Despite complaints of hip pain, staff moved the resident, contrary to facility expectations. The facility failed to implement timely and effective interventions, and their policy lacked documentation of root cause analysis for falls.
A facility failed to promptly resolve a grievance concerning a resident's care, including delayed pain medication, inadequate staffing, and lack of integrated hospice care. Despite receiving a grievance letter, the administrator did not provide a formal response, violating the facility's grievance policy.
A facility failed to promptly implement a new order for increased morphine dosage for a resident who was actively dying, resulting in a delay of nearly 27 hours before the first dose was administered. Family members reported the resident experienced pain and distress, and staff interviews confirmed the delay. The facility's administrator and DON expected immediate implementation of orders, and the resident's primary doctor emphasized the importance of timely pain management.
A facility failed to obtain a doctor's order for increasing a resident's morphine dosage and for suctioning during end-of-life care. The resident, who was moderately cognitively impaired and had a prognosis of less than six months, had her morphine dosage increased without proper documentation. Additionally, suctioning was performed by an LPN at the family's request without a doctor's order, despite hospice advice against it.
A resident with diabetes mellitus, who had moderately impaired cognition, was prescribed Humalog insulin with specific instructions to withhold it if blood glucose was below 120. Despite a reading of 102, an RN administered 30 units of Humalog, violating the facility's medication policy.
The facility did not ensure that a CNA completed mandatory Dependent Adult Abuse training within six months of employment. The CNA's previous training had expired, and the required training was not completed again until a later date. The facility's policy requires such training within six months of hire and every three years thereafter. The Administrator acknowledged the oversight.
The facility did not have the required members present at their quarterly QA meetings as per CMS guidelines. The DON was absent from one meeting, and the IP was absent from another. The Administrator was unaware of the specific required attendees, believing the required attendees were the Administrator, Medical Director, and five other staff members. The facility's QAPI Plan specified the inclusion of the Medical Director, Administrator, DON, and a direct care worker/caregiver.
A resident with dementia and other medical conditions was left unattended in a shower room without a call light, compromising their dignity and quality of life. The resident was found sitting in a wheelchair with the lights off and the shower curtain pulled around them after a CNA left the facility without completing the bath.
The facility failed to follow physician's orders for two residents regarding medication administration. One resident received the wrong medications due to simultaneous setup of multiple residents' medications, while another resident missed two doses of potassium due to improper handling and verification of medication doses.
A resident with moderate cognitive impairment and documented behavioral issues, including anxiety and depression, was given an incorrect medication, resulting in an emergency room visit for acute hypoxemic respiratory failure. The resident was mistakenly administered Seroquel, an antipsychotic not prescribed to her, instead of the ordered Lorazepam for anxiety. A Certified Medication Aide admitted to the error, and a Licensed Practical Nurse received a verbal warning for altering a medication order without proper authorization. The facility's policies on oral medication administration and receiving physician orders were not adequately followed, highlighting deficiencies in medication administration protocols.
Medications Left Undated After Opening
Penalty
Summary
The facility failed to ensure that medications were dated when opened for six residents: Resident #23, Resident #27, Resident #31, Resident #32, Resident #44, and Resident #52. On 7/1/26 at 4:08 p.m., observation of the medication cart showed an open bottle of Latanoprost Ophth for Resident #23 without an open date, an open bottle of Fluticasone Spray 50 mcg for Resident #27 without an open date, an open bottle of Dorzolamide Solution 2% for Resident #27 without an open date, an open bottle of Latanoprost Solution 0.005% for Resident #31 without an open date, an open bottle of Polymyxin B/Trimethoprim Solution for Resident #32 without an open date, an open Atrovent Aerosol Inhaler for Resident #44 without an open date, and an open bottle of Dorzolamide Solution 2% for Resident #52 without an open date. At 4:30 p.m. on 7/1/26, Staff J, an LPN, stated that the pharmacy placed yellow stickers on medications for nurses to complete with the date opened, expiration date, and initials, and that nurses were supposed to fill them out when the medication was opened. Staff J also stated that 3rd shift was supposed to check this. On 7/2/26 at 10:45 a.m., the DON stated that nurses were expected to put an open date on the bottle when it was initially opened. Review of the policy titled Labeling of Drugs, dated April 2019, stated that all medications are to be clearly and accurately labeled and labeled in accordance with accepted pharmacy practice standards.
Missing controlled medications and incomplete narcotic counts
Penalty
Summary
The facility failed to protect residents from misappropriation of property when controlled medications became missing from the medication carts for two residents. A self-report to the Department of Inspections, Appeals and Licensing documented that 54 doses of hydromorphone for one resident and 13 doses of hydrocodone for another resident were missing from the narcotic drawer. The report also stated that the torn top of one resident’s hydromorphone bubble pack was later found in the shred box, and that the resident’s narcotic count sheet was missing from the binder. The facility also reported that the other resident’s hydrocodone bubble pack and narcotic count sheet were missing, and the pharmacy record showed the resident should have had 13 doses remaining. One resident had a BIMS score of 2 out of 15 and diagnoses including heart failure, hypertension, non-Alzheimer’s disease, anxiety, and depression. That resident’s care plan addressed chronic pain and directed staff to anticipate pain needs and respond immediately to complaints of pain. The physician order was for hydromorphone 2 mg tablets, 0.5 tablet by mouth every 2 hours as needed for shortness of breath or pain, and the June MAR showed multiple doses were administered. The second resident had a BIMS score of 11 out of 15 and diagnoses including non-Alzheimer’s disease, anxiety, and depression. That resident’s care plan addressed acute pain related to fractures and dislocation, and the June MAR ordered hydrocodone-acetaminophen 5/325 mg, 1 tablet by mouth every 6 hours as needed for pain. The narcotic count sign-off logs showed multiple shifts with missing signatures or only one signature, including entries for both medication carts and the Midwest hall. Staff interviews showed that narcotic counts were not consistently completed when carts changed possession. Staff K stated she did not count narcotics with the RN when she came on duty and later found the hydromorphone bubble pack missing when attempting to administer the medication. Other staff stated they did not do narcotic counts, that counts were rarely done, and that they did not always count together at shift change. The DON stated the expectation was to count narcotics any time the cart changed possession, with both staff signing at the same time. The facility policy required the oncoming and outgoing licensed nurses to physically count and reconcile narcotics at each shift change and to document the count and signatures.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to consistently respond to activated call lights within a timely manner for one resident. Resident #47 had a BIMS score of 15 out of 15 and required partial/moderate assistance with toileting hygiene and toilet transfers. The resident’s care plan identified impaired mobility, safety concerns, functional performance deficits related to weakness from a transient ischemic attack, and risk for falls, with interventions directing staff to keep the call light within reach, encourage use of it for assistance, and provide prompt response to requests for help. During observation, Resident #47 stated the call light had been activated for several minutes and was shut off by staff without assistance being provided, and the resident reported this happened often. Staff F acknowledged shutting off the call light when unable to assist the resident to the bathroom. Review of the facility’s excess response alarms showed multiple call light response times for Resident #47 ranging from 16.7 minutes to 57.3 minutes. Staff interviews confirmed that an appropriate response time was under 15 minutes, and the DON acknowledged that call lights had exceeded 15 minutes at times. The facility policy stated all staff were to respond to an engaged call light to rule out an emergency situation and that resident needs such as transfers, toileting, and dressing were to be addressed in a timely manner.
Failure to Complete SCSA MDS After Hospice Discharge
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) MDS after a resident discharged from hospice services while remaining in the facility. Resident #22’s clinical census showed a change in primary payer from Hospice Medicaid to Medicaid effective 10/30/25, and the EHR MDS 3.0 Summary page showed the SCSA MDS was not completed when hospice services ended. A Hospice Client Coordination Note Report documented that the resident was discharged from hospice on 10/30/25 because the resident was no longer terminally ill. During interview, the Health Information Manager acknowledged that hospice services ended on 10/30/25. The MDS Coordinator stated she was responsible for completing MDS assessments, confirmed adherence to the RAI manual, and acknowledged that a SCSA assessment was required when a resident initiated hospice services or had significant improvement. She further acknowledged that Resident #22 had been admitted on hospice and later discharged from hospice services, and that the required SCSA MDS assessment was not completed at that time. The DON also confirmed that the MDS Coordinator was responsible for MDS completion and acknowledged that a SCSA assessment should have been completed when the resident was discharged from hospice services.
Failure to Submit PASRR Update After New PTSD Diagnosis
Penalty
Summary
The facility failed to submit a PASRR update after Resident #3 received a new diagnosis of PTSD. Resident #3’s MDS documented an admission date of 4/23/25, a BIMS score of 4 out of 15 indicating severe cognitive impairment, and diagnoses that included anxiety, depression, psychotic disorder, and PTSD. The resident’s prior PASRR Level I screen, dated 3/27/25, found nursing facility placement appropriate and stated that no further Level I screening was required unless the resident was known to have or suspected of having a serious mental illness, intellectual or developmental disability, and exhibited a significant change in treatment needs. A Nursing Home Audio Visual Visit note dated 6/19/25 listed visit diagnoses of generalized anxiety disorder, psychosis, and PTSD, and new orders were entered for lorazepam and mirtazapine. The EHR medical diagnoses also showed generalized anxiety disorder, psychosis, and PTSD with a date of 6/19/25. Staff C, Social Service, confirmed it was her responsibility to submit PASRR updates and acknowledged that Resident #3’s PTSD diagnosis required an updated PASRR, but the update was not submitted. The Administrator also acknowledged that an updated PASRR should have been submitted and stated that a change in mental health condition necessitated completion of a new PASRR.
Care Plans Omitted High Risk Medications
Penalty
Summary
The facility failed to include high risk medications on the care plans for two residents. One resident had a BIMS score of 9 out of 15, diagnoses of heart failure and osteoporosis, and a prognosis of less than 6 months. The MDS showed use of anticoagulant and diuretic medications in the last 7 days, and the physician orders included tramadol, furosemide, and apixaban, all identified as high risk medications with black box warnings. The resident’s care plan did not document the use of tramadol, furosemide, or apixaban. Another resident had a BIMS score of 15 out of 15 and diagnoses of polyneuropathy, restless legs syndrome, and diabetes. The MDS documented opioid use in the last 7 days, and the physician order record included hydrocodone-acetaminophen 5-325 mg, ordered daily and every 6 hours as needed for pain. The resident’s care plan, revised on 10/9/25, did not address opioid use. The facility policy required individualized comprehensive care plans with measurable objectives and timetables, developed within 7 days after completion of the comprehensive assessment and reviewed and revised after each assessment.
Inconsistent Wander Alert Checks for Elopement Risk Resident
Penalty
Summary
The facility failed to ensure interventions were consistently implemented to prevent elopement for one resident reviewed, Resident #36. Resident #36 had a BIMS score of 7 out of 15, indicating severely impaired cognition, and the MDS documented diagnoses of non-Alzheimer's dementia, depression, and heart failure. The MDS also stated that the resident wandered daily and that the current behavior status, care rejection, or wandering had worsened compared with the prior assessment. The care plan identified Resident #36 as an elopement risk/wanderer related to impaired safety awareness and included the intervention that the resident wore a wander alert to the left ankle. Surveyor review and staff interview showed the wander alert checks were not being completed consistently. A CNA stated the wander guard checks were supposed to be done daily and signed off on a monthly sheet in a binder at the nurses station, but there was no designated shift responsible for the checks. Review of the binder showed no sheet for July 2026, no sheets for March and April 2026, and multiple missed sign-offs in February, May, and June 2026. The DON acknowledged the checks were not getting done correctly and stated the expectation was that they be completed daily.
Failure to Provide Trauma-Informed Care for a Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for a resident diagnosed with PTSD, anxiety, depression, and psychotic disorder. The resident’s MDS documented severe cognitive impairment with a BIMS score of 4 out of 15 and no hallucinations or delusions at assessment, but subsequent charting showed increasing anxiety, restlessness, delusional thoughts, hallucinations, and depressed mood. Staff documented episodes of the resident stating that her arm was not attached to her body, repeatedly using the call light for nonsensical reasons, being placed in a wheelchair at the nurse’s station for supervision, calling 911 from her personal cell phone, pulling at her tube feed, asking for beer for guests, and believing people on the TV were cooking and that she needed to help them. The resident was seen via telehealth and new orders were received for mirtazapine and lorazepam, but the progress notes lacked documentation of the new diagnoses from the telehealth visit. The audio visual visit note listed diagnoses of generalized anxiety disorder, psychosis, and PTSD, with new orders for lorazepam and mirtazapine. The care plan initiated on 4/25/25 did not address the resident’s mental health diagnoses, mental health medications, triggers, goals, focus areas, or interventions when the new diagnoses were received. The DON acknowledged there were no interventions on the care plan for PTSD and that the only non-pharmaceutical interventions in place were for anxiety. Staff interviews showed inconsistent knowledge of the resident’s PTSD and related interventions. Some CNAs described comfort measures such as shutting curtains, holding the resident’s hand, and reassuring her, and one CNA stated the resident did not like men. Other staff stated they did not know what interventions were in place to identify triggers, were not aware of any PTSD interventions, and were unsure what the resident’s PTSD was from. Social services stated they had not been trained on completing trauma assessments and did not know when they were to be completed. The DON acknowledged trauma assessments were to be completed quarterly and that they had not been completed for the resident, despite the facility policy requiring trauma-informed care, social services assessment on admission and quarterly, documentation of services in the clinical record and care plan, and inclusion of interventions to mitigate triggers in the care plan.
Failure to Submit Required MDS Assessments for Certified Beds
Penalty
Summary
The facility failed to submit two completed Minimum Data Set (MDS) assessments for one of five residents reviewed, despite being dually certified for all beds with CMS. Electronic health record (EHR) review showed that for one resident, the quarterly and admission MDS assessments were either marked as 'in progress' or 'completed' but not submitted to the Centers for Medicare and Medicaid Services (CMS). Documentation incorrectly indicated that the unit was neither Medicare nor Medicaid certified, and therefore MDS data submission was not required, despite the facility's actual certification status. Interviews with facility staff, including the Business Office Manager and the DON, confirmed that the facility is dually certified and follows the RAI manual for MDS completion and submission. The DON acknowledged that the required entry and admission MDS assessments had not been submitted as mandated. The facility had been using a third party for MDS completion during a vacancy in the MDS Coordinator position, which contributed to the failure to submit the required assessments.
Failure to Implement Effective Fall Prevention Measures
Penalty
Summary
The facility failed to implement root cause analysis interventions for previous falls, resulting in a fall with a fracture for a resident with severe cognitive impairment. The resident, who was dependent on staff for various activities and had a history of falls, experienced an unwitnessed fall in her room. She was found sitting in her doorway, unable to bear weight on her left leg, and was later diagnosed with a left hip closed fracture. Despite the resident's complaints of hip pain, staff moved her from the floor, which was against the facility's expectations for handling such situations. The facility's records showed multiple falls for the resident, with interventions implemented after each incident. However, the interventions were not timely or effective in preventing further falls. The facility's policy lacked documentation of root cause analysis for each fall, and staff interviews revealed a lack of adherence to proper procedures when a resident shows signs of injury. The Director of Nursing acknowledged the need to review and ensure the appropriateness of interventions for all residents with a history of falls.
Failure to Resolve Grievance Regarding Resident Care
Penalty
Summary
The facility failed to promptly resolve and investigate a grievance related to the care of a resident, identified as Resident #2, who was moderately cognitively impaired and had a prognosis of less than six months to live. The grievance, submitted by a family member, highlighted several concerns regarding the care provided on a specific date, including a delay in administering pain medication while the resident was actively dying, incompetent nursing knowledge of state regulations by an LPN, insufficient staffing, and a lack of integrated care between hospice and facility nursing staff. Despite receiving the grievance letter, the facility's administrator did not provide a formal response to the family member's concerns. The facility's grievance policy, which was last revised in December 2022, outlines the responsibilities of the grievance official, including overseeing the grievance process, maintaining confidentiality, and issuing written decisions within 30 days. However, the administrator admitted to not providing a formal response to the family member's letter, which led to the family member's dissatisfaction and lack of resolution. The report indicates that the facility did not adhere to its grievance policy, as there was no evidence of a written decision or appropriate corrective action taken within the specified timeframe.
Delay in Implementing Increased Morphine Dosage for Resident
Penalty
Summary
The facility failed to promptly implement a new order for increased morphine dosage for a resident who was actively dying and required pain management. The resident, who was moderately cognitively impaired and had a prognosis of less than six months to live, had a new order to increase her morphine dosage to 0.5 mL every hour as needed. However, the first dose of the increased morphine was not administered until nearly 27 hours after the order was received, resulting in a delay in pain management. Interviews with family members and staff revealed that the delay in administering the increased dosage caused the resident to experience pain and distress. Family members reported having to prompt staff to check on the resident and administer the medication. The facility's administrator and Director of Nursing both stated that they expected orders to be implemented immediately upon receipt. The resident's primary doctor also indicated that timely administration of pain medication was expected if signs of pain or air hunger were present.
Failure to Obtain Proper Orders for Medication and Suctioning
Penalty
Summary
The facility failed to obtain a proper doctor's order for increasing a PRN morphine dosage for a resident who was actively dying. The resident, who was moderately cognitively impaired and had a prognosis of less than six months to live, had her morphine dosage increased from 0.5 mL to 1 mL without a documented order from a doctor. The hospice nurse and the facility's Director of Nursing (DON) were unable to find documentation of the order, and the resident's primary doctor did not have a record of authorizing the increase. The lack of documentation and proper authorization for the medication adjustment was confirmed through interviews with the hospice nurse, the DON, and the facility administrator. Additionally, the facility failed to obtain a doctor's order before suctioning the same resident during end-of-life care. A Licensed Practical Nurse (LPN) performed suctioning at the request of the resident's family, despite the hospice nurse's advice against it due to potential agitation and ineffectiveness. The DON confirmed that there was no order for suctioning, and the action was taken to comfort the family rather than based on medical necessity. These actions highlight deficiencies in following proper procedures for medication administration and end-of-life care.
Failure to Follow Insulin Administration Orders
Penalty
Summary
The facility failed to adhere to professional standards of quality in medication administration for a resident with diabetes mellitus. The resident, who had moderately impaired cognition, was prescribed Humalog insulin to be administered once daily at 7:30 AM, with instructions to withhold the insulin if the blood glucose level was below 120. On the morning of June 19, 2024, a registered nurse conducted a blood glucose test for the resident, which resulted in a reading of 102. Despite this, the nurse proceeded to administer 30 units of Humalog insulin, contrary to the physician's order to hold the medication if the blood sugar was less than 120. This action was in violation of the facility's medication administration policy, which mandates that medications be administered according to physician orders.
Failure to Complete Mandatory Abuse Training
Penalty
Summary
The facility failed to ensure that mandatory Dependent Adult Abuse training was completed within six months of employment for a Certified Nursing Aide (CNA), identified as Staff A. Personnel records indicated that Staff A was hired on a specific date and had previously completed the required training, which expired on another specified date. However, Staff A did not complete the mandatory training again until a later date, beyond the six-month requirement. The facility's policy, titled 'Abuse Prevention Policy,' mandates that employees receive two hours of training related to the identification and reporting of dependent adult abuse within six months of hire and every three years thereafter. During an interview, the Administrator acknowledged that Staff A should have completed the training within the required timeframe after the previous training expired.
Failure to Ensure Required Attendance at QA Meetings
Penalty
Summary
The facility failed to have the minimum required members present at their quarterly Quality Assurance (QA) meetings as mandated by the Centers for Medicare and Medicaid Services (CMS). The facility, which reported a census of 45 residents, conducted QA meetings on specified dates. However, the attendance sheets revealed that the Director of Nursing (DON) was absent from the meeting on 4/11/23, and the Infection Preventionist (IP) was absent from the meeting on 4/8/24. During an interview, the Administrator admitted to being unaware of the specific required attendees for the QA meetings, mistakenly believing that the required attendees were the Administrator, Medical Director, and five other staff members, without realizing the necessity of the DON and IP's presence. The facility's Quality Assurance Performance Improvement (QAPI) Plan, last updated on 1/24/22, specified that the QAPI committee should include the Medical Director, Administrator, DON, and a direct care worker/caregiver, and meet at least quarterly.
Resident Left Unattended in Shower Room
Penalty
Summary
The facility failed to treat a resident with respect and dignity, which compromised the resident's quality of life. Resident #1, who has diagnoses including hypertension, Non-Alzheimer's Dementia, anxiety, and repeated falls, was found in the shower room sitting in her wheelchair with the lights off and the shower curtain pulled around her. The resident, who has moderately impaired decision-making abilities and requires partial assistance with bathing, was left unattended without a call light within reach. This incident occurred after Staff B, a CNA, was supposed to be giving the resident a bath but was seen leaving the facility on video at 8:50 a.m. The resident was discovered missing from the dining room for breakfast, prompting a search by the facility Administrator and other staff members. The facility's policy on Resident Rights emphasizes the importance of treating residents with respect and dignity and ensuring their environment promotes their quality of life. However, the incident report and staff interviews revealed that the resident was left unattended in a vulnerable state, which is a clear violation of these rights. The Administrator confirmed that the staff is expected to treat all residents with dignity and respect, yet this expectation was not met in this case, as evidenced by the resident being left alone in the shower room without proper safety measures in place.
Failure to Follow Physician's Orders for Medication Administration
Penalty
Summary
The facility failed to follow physician's orders for two residents regarding medication administration. For Resident #3, the nurse administered the wrong medications, including Metolazone, Carvedilol, Depakote, Eliquis, Januvia, Lisinopril, Metformin, Protonix, Torsemide, and Vitamin D3, instead of the prescribed medications such as Calcium, Plavix, Depakote, Colace, Lasix, Gabapentin, Levetiracetam, Synthroid, Lisinopril, and Tylenol. This error occurred because two residents' medications were set up simultaneously to expedite the medication pass, leading to the wrong medications being given to Resident #3. The incident was documented, and vital signs and blood sugars were monitored as a result of the error. For Resident #4, the facility failed to administer additional potassium doses as ordered by the physician after a critically low potassium level was identified. The new medication cards were found in the bottom drawer of the medication cart, and it was discovered that two doses were missed. The resident's potassium level was 3.6 on a redraw. The root cause analysis indicated that the person working the medication cart was busy when the medications arrived and did not verify the doses, leading to the missed administration. The facility's administrator confirmed that staff are expected to follow physician's orders and the policy for giving oral medications.
Medication Administration Error Leads to Emergency Room Visit
Penalty
Summary
The facility failed to follow a physician's order for Resident #2, resulting in an emergency room visit. Resident #2, with a BIMS score of 10 indicating moderate cognitive impairment, had documented behavioral issues including anxiety and depression. Despite a care plan directing staff to administer medications as ordered and monitor for side effects, on 2/15/24, Resident #2 was given a one-time dose of Lorazepam for anxiety. Later that day, she was found on the floor with low vitals and subsequently sent to the emergency department due to acute hypoxemic respiratory failure. It was noted that Resident #2 was mistakenly given Seroquel, an antipsychotic medication not prescribed to her, which may have contributed to her confusion and decline. Staff B, a Certified Medication Aide, admitted to giving Resident #2 Seroquel without a physician order, leading to the medication error. The facility's policy on Oral Medication Administration outlined steps for safe medication administration, emphasizing the importance of following the "5 rights" of medication administration. Additionally, a verbal warning was issued to Staff C, a Licensed Practical Nurse, for changing a resident's medication order without obtaining proper authorization. The facility's policy on Receiving Physician Orders highlighted the legal procedure for nurses to take phone orders but lacked clarity on entering physician orders into the medication administration record. The deficiency in medication administration protocols at the facility was evident through the unauthorized administration of medications to Resident #2. Staff members acknowledged the importance of following physician orders and the correct procedures for medication administration.
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 52 citations issued within 25 miles in the last 12 months — 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 Sumner
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Tripoli Nursing & Rehab | 8.3 mi | ★★★★★ | 0 | 0 |
| Maple Crest Manor | 15.3 mi | ★★★★★ | 7 | 0 |
| Grandview Healthcare Center | 16.1 mi | ★★★★★ | 5 | 0 |
| Oelwein Health Care Center | 16.1 mi | ★★★★★ | 9 | 0 |
| Denver Sunset Home | 16.5 mi | ★★★★★ | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Hillcrest Home.
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 October 2026) and official state health department websites.