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 Nursing Center during CMS and state inspections, most recent first.
A nurse performed PEG tube care for a resident with hemiplegia, hemiparesis, and dysphagia without wearing a gown, contrary to facility policy and posted EBP signage requiring gown and gloves for high-contact device care. Interviews with staff and review of records confirmed that the resident was at high risk for infection and that proper EBP was not followed during the observed care event.
A resident with a history of asthma and moderate cognitive impairment was observed receiving oxygen at 3L/min, despite the care plan and physician's order specifying 2L/min via nasal cannula as needed for shortness of breath. Facility staff, including an LPN and the DON, confirmed that the oxygen flow rate did not match the prescribed interventions, resulting in a failure to implement the individualized plan of care.
A resident with an indwelling catheter did not have their care plan updated to include interventions for routine catheter care or specify which staff were responsible, despite care being provided and documented by CNAs. Staff interviews and record reviews confirmed the omission, which was not in accordance with facility policy requiring periodic care plan revisions.
A resident with a history of cough and wheezing was observed receiving oxygen at a flow rate above the physician-ordered 2 liters per minute, with staff confirming the oxygen was typically set higher than ordered. The LPN acknowledged the discrepancy and that the oxygen setting had not been changed, despite the order specifying a lower rate. The DON confirmed that staff are expected to check and follow physician orders for oxygen administration.
Staff failed to follow medication administration policy by leaving medications unattended at the bedside for a resident with moderate cognitive impairment and on the medication cart for another resident. Both LPNs involved acknowledged the error, and the DON confirmed that medications should not be left unattended to ensure proper administration.
Failure to Implement Enhanced Barrier Precautions During PEG Tube Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) in accordance with its own policy and current infection control standards during percutaneous endoscopic gastrostomy (PEG) tube care for one resident. During an observed care event, a registered nurse performed PEG tube care without donning a gown, despite facility policy and posted signage requiring both gown and gloves for high-contact care activities involving indwelling medical devices such as feeding tubes. Interviews with the nurse, the infection preventionist, and the director of nursing confirmed that a gown should have been worn during this procedure to protect the resident from potential contamination from the staff member's uniform. The resident involved had a history of hemiplegia and hemiparesis following a cerebral infarction, as well as dysphagia, and was assessed as having moderate cognitive impairment. Physician orders required daily cleaning and dressing of the PEG tube site. Facility records and staff interviews indicated that the resident was at high risk for infection due to the presence of the PEG tube, and that failure to use a gown during care could result in the transfer of organisms from staff to the resident.
Failure to Follow Care Plan for Oxygen Administration
Penalty
Summary
The facility failed to implement the care plan interventions as written for a resident with a history of asthma who required oxygen therapy. The resident's care plan specified the use of oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath, and the physician's order matched this intervention. However, during an observation, the resident was found receiving oxygen at a flow rate of 3 liters per minute, which was not in accordance with the care plan or physician's order. Interviews with facility staff, including an LPN and the Director of Nursing, confirmed that the oxygen should have been set at 2 liters per minute and that staff are expected to follow the care plan and physician's orders as written. The discrepancy between the oxygen flow rate provided and the documented care plan and physician's order was acknowledged as a failure to follow the individualized plan of care. The resident involved had a moderately impaired cognitive status and diagnoses including cough and wheezing, and was receiving oxygen therapy at the time of the deficiency.
Failure to Revise Care Plan for Catheter Care
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident with an indwelling catheter to include specific interventions for routine catheter care. Observation revealed the resident had catheter tubing present, and record review showed that while CNAs documented catheter care tasks every shift, the care plan itself did not specify how often catheter care should be performed or which staff were responsible for providing the care. Interviews with staff confirmed that catheter care was being performed and documented, but the care plan was not updated to reflect these interventions or assign responsibility. The resident involved had been admitted with diagnoses including acute kidney failure and was noted to have moderately impaired cognition. The facility's policy required that care plans be reviewed and revised periodically to reflect the services provided, but this was not done for the resident's catheter care. The deficiency was identified through observation, record review, and staff interviews, which confirmed the omission in the care plan documentation.
Oxygen Administration Exceeded Physician Order
Penalty
Summary
The facility failed to ensure that oxygen was administered according to the physician's order for a resident with a history of cough and wheezing. The physician's order specified oxygen via nasal cannula at 2 liters per minute as needed for shortness of breath or oxygen saturation of 93% or below. However, during multiple observations, the resident was receiving oxygen at a flow rate above 3 liters per minute, with one instance recorded at 3.4 liters per minute. The LPN on duty confirmed that the oxygen was typically set at 3 liters per minute and acknowledged that the setting had not been changed that morning, despite the physician's order specifying a lower rate. Further interviews revealed that the LPN was aware that the oxygen should not be adjusted without a new physician order and that exceeding the prescribed rate could have adverse effects. The Director of Nursing also confirmed that nurses are expected to check and follow the physician's order every shift. The resident involved had moderately impaired cognition, as indicated by a BIMS score of 9, and was receiving oxygen therapy at the time of the deficiency.
Medications Left Unattended at Bedside and on Medication Cart
Penalty
Summary
Surveyors identified that staff failed to follow facility policy regarding the secure handling and administration of medications for two residents. In one instance, an LPN administered Polyethylene Glycol 3350 mixed in water to a resident with moderate cognitive impairment and left the medication at the bedside, instructing the resident to finish it at her own pace. The LPN later acknowledged that this practice was against policy, as it was not possible to confirm whether the full dose was consumed, and the medication should not have been left unattended. In another instance, an LPN prepared Ipratropium-Albuterol Inhalation Solution for a resident with moderate cognitive impairment and left the medication vial unattended on top of the medication cart while retrieving supplies. The LPN admitted awareness that this was improper and could result in another resident accessing the medication. The DON confirmed that facility policy prohibits leaving medications unattended on carts or in resident rooms, emphasizing that staff are expected to observe medication administration to ensure compliance with orders.
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 10 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 Magee
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bedford Care Center Of Mendenhall | 10.5 mi | ★★★★★ | 1 | 0 |
| Ms Care Center Of Raleigh | 15.2 mi | ★★★★★ | 0 | 0 |
| Arrington Living Center | 20.1 mi | ★★★★★ | 0 | 0 |
| Landmark Of Collins | 20.5 mi | ★★★★★ | 2 | 0 |
| Jefferson Davis Community Hospital Ecf | 21.7 mi | ★★★★★ | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Hillcrest Nursing 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.