Above average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Home during CMS and state inspections, most recent first.
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.
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.
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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.
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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 | ★★★★★ | 0 | 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 |
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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.