Below 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 Manor Nursing Center during CMS and state inspections, most recent first.
A CMA failed to maintain physical support of a resident requiring assistance during a transfer, letting go of the resident to close a bathroom door, which resulted in the resident falling. The resident, who had intact cognition and required staff support for transfers, reported pain and was evaluated at a hospital. Facility policy and best practice were not followed, as confirmed by staff interviews.
A resident experienced multiple falls, primarily while attempting to use the bathroom independently during early morning hours, resulting in injuries including a hip fracture. Despite recognition of this pattern by both staff and the resident's POA, and a specific request for increased monitoring during high-risk times, the care plan was not updated to include targeted interventions such as scheduled checks. The lack of communication and failure to revise the care plan contributed to ongoing incidents.
A resident with a history of falls while attempting to use the bathroom during early morning hours suffered multiple incidents, including a hip fracture requiring surgery, due to staff not providing targeted supervision or updating the care plan despite repeated requests from the POA and awareness of the risk. Communication lapses between staff and management contributed to the deficiency.
A resident was allowed to self-administer insulin without a documented assessment to determine their ability to do so safely, despite facility policy requiring such an evaluation. Nursing staff routinely set up the insulin injector and permitted the resident to inject themselves, but neither an order nor an assessment for self-administration was found in the medical record. Facility leadership and staff were unaware of the need for or existence of the required documentation.
A comprehensive assessment for a resident contained conflicting information regarding antipsychotic medication use, with the MDS indicating both use and non-use, despite the MAR confirming administration of Latuda. The DON and Corporate VP acknowledged the inaccuracy, noting that only spot checks of the MDS coordinator's work were performed.
A resident was discharged from the facility, but instead of completing and submitting the required discharge assessment, staff mistakenly completed a quarterly assessment. This error was confirmed by facility leadership during review of the electronic health record.
A resident requiring moderate assistance with bathing did not consistently receive scheduled showers, with documentation missing for several occasions. The resident reported not always receiving baths as scheduled, and staff interviews revealed that showers and refusals should be documented, but lack of documentation made it unclear if care was provided.
A resident with heart failure and hypertension who complained of cough and congestion did not receive a physician-ordered RSV test. The order was not entered into the computer, and the facility was out of necessary swabs. The facility did not follow up to ensure the sample was collected.
A resident with neuromuscular dysfunction of the bladder and a stage IV pressure ulcer, who was totally dependent on staff, did not consistently receive care with required enhanced barrier precautions. During wound and incontinent care, a CNA was observed not wearing a gown as required, despite staff acknowledging that gowns should be used for residents on enhanced barrier precautions.
A resident with dementia, identified as an elopement risk, was found outside the facility due to non-functioning Wander Guard alarms on two doors. Staff interviews revealed that residents at risk for wandering wore Wander Guard bracelets, and alarms were supposed to be tested weekly. However, monitoring of the system had not been initiated until the incident occurred.
Failure to Provide Adequate Supervision During Resident Transfer Resulting in Fall
Penalty
Summary
A certified medication aide (CMA) failed to provide adequate supervision to prevent a fall for one resident who required staff assistance for transfers. According to facility policy, staff are expected to implement interventions based on residents' specific risks to prevent falls. The resident involved had intact cognition and required physical support from staff for transfers, as documented in their assessment. On the day of the incident, the CMA was assisting the resident back from the bathroom but turned away to close the bathroom door, completely letting go of the resident. During this moment, the resident fell to the floor, as confirmed by both the CMA and a witness. Following the fall, the resident complained of hip pain and was transferred to a local hospital for evaluation, though no injuries were ultimately found. The resident's transfer status was subsequently elevated from a one-person to a two-person transfer, and pain medication was prescribed for reported pain. Interviews with the CMA and the ADON confirmed that the CMA should not have let go of the resident during the transfer and that this action was not in accordance with facility policy or best practice.
Failure to Update Care Plan for Recurrent Falls
Penalty
Summary
The facility failed to update a resident's care plan to include specific interventions to prevent a recurring pattern of falls, despite multiple documented incidents. The resident experienced several falls, most of which occurred between 3:00 a.m. and 5:00 a.m. while attempting to go to the bathroom independently. These falls resulted in injuries, including a laceration, skin tear, abrasion, and ultimately a hip fracture that required surgical intervention. The care plan was revised after some of these incidents, but did not include targeted interventions such as scheduled checks during the high-risk time frame. Progress notes and interviews revealed that both staff and the resident's power of attorney (POA) recognized the pattern of falls occurring during early morning hours. The POA specifically requested that staff check on the resident during these times to help prevent further incidents. An LPN confirmed having this conversation with the POA but did not communicate the request to the night shift or management, and the intervention was not added to the care plan. The Director of Nursing (DON) acknowledged that information about the resident's fall pattern and the POA's request should have been communicated to management and incorporated into the care plan. The facility's policy required the interdisciplinary team to develop and implement a comprehensive, person-centered care plan, but this was not followed in the case of this resident, resulting in a lack of appropriate interventions to address the identified risk.
Failure to Provide Supervision to Prevent Repeated Resident Falls
Penalty
Summary
Staff failed to provide adequate supervision to prevent repeated falls for a resident with a known history of attempting to go to the bathroom independently during early morning hours. The resident experienced multiple falls between 3:00 a.m. and 5:00 a.m., as documented in several progress notes, with incidents resulting in injuries including a head laceration and, ultimately, a left hip fracture that required surgical intervention. The facility's fall management policy required staff to identify and implement interventions based on the resident's specific risks, but this was not effectively carried out. Despite the resident's power of attorney (POA) repeatedly notifying staff and requesting that the resident be checked during the high-risk time frame, this information was not formally communicated to management or incorporated into the resident's care plan. The LPN who received the POA's request did not ensure the intervention was relayed to the night shift or documented for agency staff, resulting in a lack of targeted supervision during the times when the resident was most at risk for falls.
Failure to Assess Resident for Safe Self-Administration of Insulin
Penalty
Summary
The facility failed to ensure that a resident who self-administered insulin was properly assessed for the ability to safely self-administer medication, as required by facility policy. During an observation, a nurse was seen handing an insulin injector to a resident, who then administered the injection without checking the dose. The resident had a physician's order for insulin and had been self-administering for approximately one year, with staff routinely setting up the injector and allowing the resident to inject themselves. However, there was no documented assessment in the medical record to determine if the resident was clinically appropriate or safe to self-administer their medication. Interviews with nursing staff and administration revealed a lack of awareness regarding the need for an assessment or a specific order for self-administration. The DON and ADON were not initially aware of any residents self-administering medications and could not locate an assessment or order for the resident in question. The facility's policy required an evaluation of the resident's mental and physical abilities before permitting self-administration, but this process had not been followed for the resident observed.
Inaccurate MDS Assessment for Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure the accuracy of a comprehensive assessment for one resident, as required by policy. Specifically, the annual Minimum Data Set (MDS) assessment for the resident contained conflicting information in Section N, indicating both that the resident was and was not receiving antipsychotic medications. Review of the resident's medication administration record (MAR) confirmed that the resident had been administered the antipsychotic medication Latuda during the week prior to the assessment. Interviews with the Corporate Vice President and the Director of Nursing (DON) confirmed the inconsistency in the MDS and acknowledged that the resident was indeed taking an antipsychotic at the time of the assessment. The DON stated that while the Corporate VP spot-checked the MDS coordinator's work, they themselves did not review each assessment, and the MDS was found to be inaccurate.
Failure to Complete and Submit Required Discharge Assessment
Penalty
Summary
The facility failed to ensure that a required discharge assessment was completed and submitted to the Centers for Medicare and Medicaid Services for one resident. According to the records, the resident was discharged on 10/25/24, but the electronic health record only showed a quarterly assessment completed on that date, with no evidence of a discharge assessment. During an interview, the Corporate Vice-President of Operations confirmed that a quarterly assessment was completed instead of the required discharge assessment due to an error.
Failure to Provide Scheduled Bathing Assistance
Penalty
Summary
The facility failed to ensure that a resident who required moderate assistance with bathing received scheduled showers as required. According to the facility's policy, residents unable to perform activities of daily living independently should receive necessary services to maintain personal hygiene. Record review showed that, out of 18 scheduled opportunities, the resident did not have showers documented on seven occasions. The resident reported that they were supposed to receive baths twice weekly but sometimes did not, and when they requested a shower, staff would sometimes promise to return but did not always follow through. Staff interviews confirmed that showers should be documented and refusals noted, but if there was no documentation, staff could not confirm whether a shower was provided.
Failure to Complete Physician-Ordered Laboratory Test
Penalty
Summary
The facility failed to ensure that laboratory tests were completed as ordered by the physician for one resident. The resident, who had diagnoses including heart failure and hypertension and was assessed as having no cognitive impairment, complained of cough and congestion. The physician was notified and ordered guaifenesin and an RSV test. However, there was no physician order for the RSV test documented in the health record, nor were there any results for an RSV test collected on the date in question. Interviews revealed that the order for the RSV test was not entered into the computer, and the facility was out of swabs needed for the test. The lab company was scheduled to bring more swabs, but the facility did not follow up to ensure the sample was collected.
Failure to Consistently Implement Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to ensure that enhanced barrier precautions were consistently implemented for a resident requiring such measures. During wound care and incontinent care provided to a resident with neuromuscular dysfunction of the bladder and a stage IV pressure ulcer, a CNA was observed not wearing a gown as required, while the RN did wear a gown during wound care. The resident was assessed as severely impaired for daily decision making and totally dependent on staff for care. Staff interviews confirmed that gowns should have been worn during direct care for residents on enhanced barrier precautions, but this protocol was not followed during the observed care activities.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Alarm System
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident diagnosed with dementia, who was identified as being at risk for wandering. The resident's care plan documented a history of attempts to leave the facility unattended. An incident occurred where the resident was found walking beside the street in front of the facility, indicating a lapse in supervision and security measures. Upon investigation, it was discovered that the Wander Guard alarms on the southwest and northwest doors were not functioning, as they were not installed. Interviews with staff revealed that residents who wandered were supposed to wear a Wander Guard bracelet, and the alarms were expected to sound if a resident approached within 10-15 feet of a door. The maintenance supervisor was responsible for testing the Wander Guard system weekly, but the monitoring of the system had not been initiated until the date of the incident. This lack of monitoring and testing contributed to the failure in preventing the resident's elopement.
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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
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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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Blackwell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willow Haven Nursing Home | 6.9 mi | — | 0 | 0 |
| Ponca City Nursing & Rehabilitation Center | 11.6 mi | ★★★★★ | 0 | 0 |
| Shawn Manor Nursing Home | 13.8 mi | ★★★★★ | 0 | 0 |
| Bradbury Commons | 14.8 mi | ★★★★★ | 0 | 0 |
| Arkansas City Presbyterian Manor | 24.2 mi | ★★★★★ | 4 | 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.