Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 Home during CMS and state inspections, most recent first.
Unlabeled frozen food items were found in the kitchen walk-in freezer, including multiple clear bags of breaded items, shredded/cut food, patties, and an unlabeled wrapped food object. One bag of patties was also found on the floor. DC-A confirmed the items should have been labeled and dated, and the DD confirmed the freezer items should have had contents and date labels.
The facility failed to maintain an effective infection prevention and control program because infection tracking and trending documentation was incomplete and infection counts in QA notes did not match the Infection Surveillance Report. The IP confirmed the report lacked key details such as room numbers, signs and symptoms, labs, and antibiotic days, and the wound nurse’s documented audits were education rather than actual observations. The facility also failed to use proper hand hygiene and glove technique during incontinent care for a resident with severe cognitive impairment, bowel and bladder incontinence, and a recent UTI; NAs were observed using soiled gloves, reusing wipes, handling soiled linens, and leaving the room without hand hygiene.
Failure to provide ordered oral care for three residents. Residents with cognitive impairment and ADL assistance needs had care plans requiring oral hygiene, but surveyors observed unopened toothbrush supplies in rooms and bathrooms and saw morning care completed without brushing teeth or other oral care. Staff also left one resident without hearing aids during care, and the DON stated morning care should include brushing teeth and other hygiene tasks.
Failure to Follow Bowel Elimination Protocol: Two residents with bowel management needs did not receive the facility’s required constipation interventions when bowel movements were absent. One resident with constipation, ulcerative colitis, and severe cognitive impairment had repeated gaps in bowel movement documentation, and staff confirmed the bowel protocol was not started on time. Another resident with stroke-related hemiplegia, dementia, and opioid use for pain had no bowel movements over several days, yet the MAR showed no documented administration of the PRN constipation medication, and an MA confirmed the resident should have received bowel intervention.
Failure to prevent and address pressure ulcer development: A resident identified as at risk for skin breakdown developed an in-house acquired unstageable L heel wound, yet the care plan did not address the existing ulcer or include interventions to prevent additional pressure injuries. Observations showed the resident’s feet pressed against the bed footboard, heels resting on a recliner footrest crossbar, and no offloading in place for the R foot; an RN confirmed no interventions were in place to prevent additional pressure ulcers.
Failure to Provide Toileting and UTI Prevention Care: A resident with severe cognitive impairment, dependent toilet use, and recurrent urinary and bowel incontinence had repeated UTIs, C-Diff, and eventual urosepsis. Survey observations showed the resident sitting for long periods in common areas and a recliner without toileting assistance or hydration being offered, and staff were observed providing peri-care after incontinence rather than toileting the resident. The DON confirmed staff were expected to toilet residents before and after meals and before activities.
Failure to monitor two residents after dialysis treatments. Both residents had ESRD and were scheduled for dialysis three times weekly, with care plans requiring vital signs and fistula/access monitoring after dialysis. Review of dialysis communication records showed repeated missing post-dialysis vital signs for both residents, and one resident also had a dialysis note about a large fluid gain and another note about a CVC dressing issue. Staff interviews confirmed vital signs were taken before dialysis, but no additional post-return care was provided and no extra monitoring was done after dialysis.
A resident with CAD, Afib, DM2, dementia, macular degeneration, and a fall history had active orders for MiraLAX 17 g BID and docusate 100 mg BID for constipation. Bowel records showed frequent BMs, often 2-3 per day, and the resident said this was too often and that they were taking meds to prevent constipation. The DON confirmed the resident was using MiraLAX to maintain routine BMs and was unsure why it had been ordered BID.
A resident with chronic kidney disease and congestive heart failure reported shoulder pain after using a sink to stand, later diagnosed with a left shoulder and thoracic compression fracture. The DON did not investigate the cause of the compression fracture after being notified by the provider, contrary to facility policy requiring thorough investigation of such injuries.
A resident was prescribed a prophylactic antibiotic without a clear indication or stop date, contrary to the facility's Antibiotic Stewardship Policy. The resident had a history of urinary tract infections, and the antibiotic was ordered by a urologist. However, there was no clinical documentation supporting its use, and it was not reviewed by the pharmacist or physician.
Unlabeled Frozen Food Items in Walk-In Freezer
Penalty
Summary
The facility failed to label frozen food packages with contents or dates in the kitchen walk-in freezer. A review of the facility’s Food Storage Policy, last revised November 2023, stated that all foods shall be clearly labeled with contents, dated with the opening date, and discarded if not dated or expired, and that frozen foods shall be dated and properly rotated. During an observation on 5/04/2026 at 12:43 PM, surveyors found multiple unlabeled frozen food items on the first food rack to the left in the walk-in freezer, including clear plastic bags of breaded food items, shredded/cut food, pale brown patties, and an unlabeled food object wrapped in plastic. One bag of 10 breaded patties was found on the floor. Dietary Cook-A confirmed the bag of meat patties on the floor should have been labeled, dated, and not on the floor, and also confirmed the bags did not identify the contents or whether the items were cooked or uncooked meat. The Director of Dietary later confirmed the bags in the freezer should have been labeled with contents and relevant dates.
Infection Control Program and Hand Hygiene Failures
Penalty
Summary
The facility failed to maintain an infection prevention and control program that fully tracked and trended infections and failed to implement interventions for identified concerns related to antibiotic overuse. Record review showed the infection control binder contained blank facility maps and dining room seating charts for multiple months, and the Infection Surveillance Report did not include complete room numbers, signs and symptoms, lab information, or number of days on antibiotics. The Infection Preventionist confirmed the binder documentation was incomplete and that the report only showed the number and type of infections and medication ordered. Quarterly QA meeting notes documented urinary tract infection counts that did not match the Infection Surveillance Report for the same time periods. The DON confirmed the facility used the report to track and trend infections but stated it was not working accurately during the first part of the year. The facility’s Quality Performance Improvement Plan for the post-COVID outbreak indicated weekly audits of peri-care and catheter care, toileting and incontinence care every two hours, and re-education on hand hygiene and glove changes, but the wound nurse audits were actually education with return demonstration rather than observations of actual care. No further documentation was found showing actual peri-care observations or audits. The facility also failed to use handwashing and gloving techniques to prevent potential cross contamination during personal care for Resident 10. The resident had a BIMS score of 3, was dependent for toilet use, was occasionally incontinent of urine and frequently incontinent of bowel, and had a UTI within the last 30 days. During observed incontinent care, two NAs entered the room and applied gloves without hand hygiene, used the same gloves during multiple steps of peri-care, reused wipes multiple times, handled soiled briefs and linens, and one NA dipped soiled gloves into an unlabeled specimen cup to apply cream and powder. One NA changed gloves without hand hygiene, the other kept soiled gloves on, and one NA left the room without completing hand hygiene. The DON confirmed staff were expected to perform hand hygiene with glove changes.
Failure to Provide Ordered Oral Care
Penalty
Summary
The facility failed to provide oral care in accordance with residents’ assessed needs and care plans for three sampled residents. Facility policy required oral care at least twice daily and as needed, and the DON stated morning care expectations included brushing teeth, along with other hygiene tasks. The deficiency was identified through observation, interview, and record review, and involved residents who had documented needs for assistance with grooming and hygiene tasks. Resident 10 had a BIMS score of 3, required substantial/maximal assistance with bed mobility, transfers, and eating, and was dependent for toilet use. The resident’s care plan directed staff to assist with brushing teeth twice a day and as needed. Surveyors observed unopened oral care supplies in the room on one day, and during morning care on another day staff completed peri-care, dressing, and grooming but did not provide oral care before the resident was transported from the room. NA-B confirmed staff missed the opportunity to provide oral care in accordance with the care plan. Resident 37 had a BIMS score of 2, required assistance or dependence with several ADLs, and used oxygen therapy. The resident’s room also contained unopened oral care supplies, and during observed morning care the resident repeatedly stated they could not hear and needed hearing aids, which staff said were in the med cart and would be obtained later. The resident continued without hearing aids during care, and no oral care, hand washing, or face washing was offered or provided before the resident left the room. Resident 40 had dementia and a quarterly MDS indicating cognitive impairment and a need for supervision with oral hygiene; the care plan called for set-up help with grooming and hygiene. Surveyors observed oral hygiene products left unopened or still in packaging in the resident’s bathroom across multiple observations, with no evidence the toothbrush had been used.
Failure to Follow Bowel Elimination Protocol
Penalty
Summary
The facility failed to follow its bowel elimination protocol for two residents with documented bowel management needs. The policy required nursing to monitor bowel patterns and report constipation, diarrhea, impaction symptoms, abdominal distention, and changes in bowel habits, with PRN and scheduled bowel medications administered per physician orders. The protocol also directed interventions beginning after 48 hours without a bowel movement, including offering fluids or natural laxatives, followed by Milk of Magnesia at 72 hours, a suppository at 96 hours, and escalation to an enema at 120 hours if no bowel movement occurred. One resident had diagnoses including constipation, ulcerative colitis, and dementia, with severe cognitive impairment, bowel incontinence, and substantial assistance needed for toileting transfers. The resident’s record showed multiple stretches without a bowel movement across several dates in January, March, and April 2026. Although the resident had PRN orders for bisacodyl suppository and Milk of Magnesia, staff did not initiate the bowel elimination protocol by the second day without a bowel movement as required. An LPN confirmed the resident did not have bowel movements during the identified date ranges and stated the protocol interventions should have been started by day 2 but were not. The DON also confirmed the staff did not follow the facility’s bowel elimination protocol for this resident. The second resident had diagnoses including cerebral infarction, right-sided hemiplegia and hemiparesis, adult failure to thrive, muscle weakness, polymyalgia rheumatica, pain, dementia with agitation, and disorientation. The resident was cognitively impaired, dependent on toileting hygiene, incontinent of bowel and bladder, and had a care plan focused on impaired mobility, incontinence, and opioid use for pain management. The resident had a fentanyl patch order and only a PRN docusate sodium order for constipation, with no routine bowel medications ordered. The bowel documentation showed no bowel movement over multiple consecutive days, and the MAR showed no documentation that the PRN docusate sodium was administered during those periods. A medication aide confirmed that residents without bowel movements should receive prune juice on day 2, Milk of Magnesia on day 3, and a suppository on day 4, and confirmed that this resident should have been given medication to help with constipation.
Failure to Prevent and Address Pressure Ulcer Development
Penalty
Summary
The facility failed to evaluate and implement interventions to prevent additional pressure ulcer development for a resident identified as at risk for skin breakdown. The resident’s record showed dependence for toileting, partial/moderate assistance with bed mobility, and dependence with transfers. The care plan identified the resident as at risk for skin breakdown, but there was no evidence that the resident’s left heel pressure ulcer was addressed or that interventions were put in place to treat the existing wound or prevent additional pressure ulcers to the right heel from developing. Braden Scale assessments showed moderate to mild risk scores over time, and no further Braden assessments were completed after the last one on 03/10/2026. Later skin evaluation documented a new in-house acquired unstageable wound to the left heel measuring 1.4 cm by 1.2 cm with 100% eschar. Observations showed the resident lying in bed with the bottoms of both feet pressed against the footboard, with no heel offloading to the right foot and a soft blue boot only on the left foot. Additional observations showed the resident crying and grimacing during transfers and shoe application related to left foot pain, sitting in a recliner with heels resting on the crossbar of the footrest, and continuing to have no interventions in place to prevent additional pressure injuries to the right foot. An RN confirmed there were no interventions in place to prevent additional pressure ulcers and that the resident was at risk while sitting in the recliner with heels on the footrest crossbar.
Failure to Provide Toileting and UTI Prevention Care
Penalty
Summary
Appropriate care for residents who are continent or incontinent of bowel and bladder, appropriate catheter care, and appropriate care to prevent UTIs was not provided for Resident 10. The resident had severe cognitive impairment with a BIMS score of 3, was dependent for toilet use, and was documented as occasionally incontinent of urine and frequently incontinent of bowel. The care plan directed staff to offer or assist with frequent toileting around meals, activities, and at bedtime to promote continence, but the record showed recurrent infections and multiple antibiotic courses during 2026. Progress notes documented a series of urinary and systemic illnesses, including a UTI treated with IV Rocephin and oral cephalexin after an emergency transfer on 02/20/2026, followed by positive GI panel for C-Diff and leukocytosis/UTI on 02/24/2026. The resident continued to have loose stools, weakness, decreased eating and drinking, and abnormal UA results in March 2026, with a new order for Cipro for UTI that was later discontinued when the urine culture was negative. On 04/02/2026, the resident was transferred to the hospital with tremors and tachycardia and was admitted with urosepsis; hospital discharge documentation noted sepsis from urinary source and positive C-Difficile infection. Survey observations showed the resident sitting in common areas and the nurse's station for extended periods without being toileted or offered hydration. On one observation, the resident remained in the common area until becoming incontinent of bowel, was taken to the room for peri-care, and then returned to the common area without being placed on the toilet. Additional observations showed the resident in therapy, the dining room, the common area, and later in a recliner, with no toileting assistance offered during the observation period. During morning care, the resident was incontinent of bowel and later, after a brief was changed, urinated on the new brief and bedding, requiring another change. The DON confirmed staff were expected to toilet residents before and after meals and before activities.
Failure to Monitor Residents After Dialysis Treatments
Penalty
Summary
The facility failed to monitor 2 residents receiving dialysis for adverse effects after treatments. The facility policy titled Hemodialysis Access stated that the dialysis site should be assessed on admission/readmission, upon return from dialysis, and with any change in condition, and that after residents return from dialysis staff should assess the dressing, check for bleeding, verify thrill and bruit, monitor for hypotension, and document findings. The facility census was 62 residents. Resident 6 had end stage renal disease, dependence on renal dialysis, pulmonary hypertension, cardiomegaly, systolic and diastolic heart failure, coronary artery disease, type 2 diabetes mellitus, and bipolar disorder. The resident’s MDS showed a BIMS score of 15 out of 15, indicating cognitive intactness. The care plan directed staff to obtain, record, and report vital signs per protocol and to assess the fistula for inflammation, pain, and bleeding after dialysis, as well as to listen for bruit and palpate for thrill. Review of dialysis communication records from 2/27/26 through 5/4/26 showed 28 separate dialysis dates, and all 28 were missing vital signs after the resident returned to the facility post-dialysis; 7 of those 28 records also lacked vital signs before or after dialysis. One dialysis note on 3/23/26 documented a very large fluid gain over the weekend, inability to remove all extra fluid, and a request that the facility stress fluid restrictions with the resident. Resident 20 had end stage renal disease, COPD, type 2 diabetes, hypertension, and coronary artery disease, and the quarterly MDS showed a BIMS score of 15 out of 15. The care plan stated the resident had dialysis three times a week and that staff would obtain, record, and report vital signs per protocol. Review of dialysis communication records from 3/2/26 through 5/6/26 showed 26 separate dialysis dates, and all 26 were missing vital signs after the resident returned to the facility post-dialysis. On 4/10/26, dialysis notes stated no dressing was on the CVC site and requested that the CVC dressing not be removed and that infection symptoms be monitored due to exposure. A facility document dated 5/5/26 stated the resident went to the hospital for a procedure, and an interview with the LPN confirmed the resident was at the hospital having a new fistula created. A nursing progress note documented the resident returned from the hospital on 5/5/26, the right fistula was palpated, and the incision was intact, but no other information about the resident’s condition after fistula placement was documented.
Unnecessary bowel regimen medications ordered despite frequent bowel movements
Penalty
Summary
The facility failed to ensure that one resident’s drug regimen was free from unnecessary bowel management medications. Resident 7 was admitted with diagnoses including coronary artery disease, atrial fibrillation, Diabetes Mellitus Type 2, dementia, macular degeneration, and a history of falling. The resident’s most recent quarterly MDS showed a BIMS score of 15 out of 15, indicating cognitive intactness. Physician orders showed active orders for polyethylene glycol 17 grams twice daily and docusate sodium 100 mg twice daily, both ordered to treat constipation beginning 4/24/25. Review of the bowel record in PCC showed that during April 2026 the resident had bowel movements documented on at least 2 shifts per day for 13 of 30 days and no bowel movements documented on 1 day. During March 2026, bowel movements were documented on at least 2 shifts per day for 19 of 31 days, and during February 2026, bowel movements were documented on at least 2 shifts per day for 16 of 28 days with 1 day of no bowel movement charted. The resident stated their usual routine was having 2-3 bowel movements per day and felt this was too often, and also stated they were taking medications to prevent constipation. The DON confirmed the resident complained about their bowels, confirmed the resident was taking MiraLAX to aid in having routine bowel movements, and stated they were unsure why MiraLAX was ordered twice daily.
Failure to Investigate Resident Fracture
Penalty
Summary
The facility failed to thoroughly investigate a fracture sustained by one resident. According to the facility's policy, the Director of Nursing (DON) is responsible for directing investigations into possible abuse or injury. The resident in question, who was cognitively intact and required varying levels of assistance with daily activities, reported using a sink to assist in standing and subsequently experienced pain and a popping sound in the left shoulder. The resident was sent to the emergency room, where initial X-rays were reported as normal, but the resident was admitted for an exacerbation of congestive heart failure. Upon the resident's return to the facility, documentation indicated diagnoses of a left acromion fracture and a compression fracture of the 8th thoracic vertebra. The facility was notified by the resident's provider of these injuries, but the DON confirmed that no investigation was conducted to determine the possible or probable cause of the compression fracture. This lack of investigation was contrary to facility policy and regulatory requirements to respond appropriately to all alleged violations or injuries.
Lack of Indication for Prophylactic Antibiotic Use
Penalty
Summary
The facility failed to provide a clear indication and rationale for the use of a prophylactic antibiotic for one resident. The resident, who was cognitively intact, had a history of urinary tract infections and was on an antibiotic regimen without a documented indication or stop date. The antibiotic, Cephalexin, was prescribed by a urologist, but there was no clinical documentation supporting its continued use, nor was it reviewed by the pharmacist or physician. Interviews with the registered nurse and the Director of Nursing confirmed the lack of a clear indication and rationale for the antibiotic's use. The facility's Antibiotic Stewardship Policy requires monitoring of antibiotic regimens, including reviewing clinical documentation and compliance with therapy duration, which was not adhered to in this case. The deficiency was identified during a review of the resident's records and interviews with facility staff.
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 Mccook
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Society - Decatur County | 26.6 mi | ★★★★★ | 19 | 0 |
| Good Samaritan Society - Atwood | 34 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Hillcrest Nursing 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 July 2026) and official state health department websites.