Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hillcrest Healthcare Center during CMS and state inspections, most recent first.
Care plan meetings were not consistently held or documented, and residents were not included in their own care planning. One resident’s care plan was also not revised after she was fitted for an upper denture and was awaiting delivery. The DON and DoSS acknowledged that care plan meetings were behind, and records showed missing quarterly reviews and no documented invitations or attendance for some residents.
Improper POST Form Consent for Resident Without Capacity: A resident with vascular dementia, major depressive disorder, hallucinations, unspecified mood disorder, and anxiety signed a POST form selecting CPR with full treatment even though a physician determined the resident lacked capacity to make medical decisions. The resident’s representative did not sign the form, and the DoA acknowledged the error during survey review.
Failure to document NOMNC delivery to a resident representative. For one resident sampled for beneficiary notification, Social Services completed the NOMNC verbally by phone, but the form had only one facility signature and there was no record that the notice was mailed to the representative. The DOSS confirmed the lack of documentation and stated the facility does not use certified mail.
PASRR Not Updated for New Mental Health Diagnoses: A resident with existing mental health diagnoses later developed PTSD and Major Depressive Disorder, but the facility did not update the PASRR or submit it for Level II review. The PASRR had listed anxiety, depression, and auditory hallucinations, and staff confirmed it needed to be updated after the new diagnoses were identified.
Failure to provide daily ambulation assistance after therapy discharge. A resident who had been discharged from PT with orders for daily walking with nursing assistance and a RW was documented as walking only once over three months. Staff interviews confirmed nursing staff were expected to assist with daily ambulation, but CNAs reported they did not regularly walk the resident and had not seen her walk.
Medication Storage and Labeling Deficiencies: An insulin pen for a resident was found in a med cart past its use-by date, and an LPN confirmed it should have been discarded. In a separate finding, a multi-use PPD vial in the med refrigerator had not been dated when first opened, despite facility policy requiring the opened date to be recorded and the vial insert stating it should be discarded after 30 days in use.
A resident with a Full Code status was found unresponsive and without vital signs. An LPN and a nurse aide initiated CPR but discontinued resuscitation efforts several minutes before EMS arrived, contrary to facility policy and the resident's POST form. The failure to continue CPR until EMS arrival resulted in the resident's death and was confirmed through staff interviews and facility investigation.
A resident with a history of falls, poor safety awareness, and multiple medical conditions was left unsupervised on a shower bed after a nursing assistant lowered the bed rail and turned away. The resident slid off the bed, sustaining a head laceration and hematoma that required ER treatment. The care plan's fall prevention interventions were not followed in this instance, resulting in injury.
Staff served beans that were scorched, with a strong smoky odor and visible burnt bits, resulting in an overcooked, burnt taste. The Culinary Account Manager confirmed awareness of the issue, stating the cook had scraped the bottom of the pan, leading to the burnt beans being served to residents.
Surveyors observed that staff did not consistently use barriers when placing multi-dose medication containers on resident surfaces during medication administration, and these containers were then returned to the medication cart, increasing the risk of cross-contamination. Enhanced Barrier Precautions were not implemented for a resident with pressure ulcers, and two residents used wheelchairs with damaged coverings that could not be properly cleaned, all of which were acknowledged by staff as infection control issues.
The facility failed to provide the required SNF ABN and NOMNC forms to two residents prior to the end of their Medicare Part A skilled services. In both cases, therapy services ended after residents met their goals, but the necessary beneficiary protection notifications were not issued, as confirmed by staff interviews and record review.
A resident with pressure ulcers did not receive modular protein and multivitamin with zinc supplements as recommended by the wound care service. Review of the medical record showed these supplements were not ordered, and there was no documentation explaining the omission. The DON confirmed the lack of documentation and noted that the physician typically does not order the multivitamin with zinc.
A resident with broken and missing teeth was identified as needing all remaining teeth extracted, with a referral made for oral surgery. Despite documentation of the referral and staff awareness, an LPN reported being unable to confirm that an appointment with an oral surgeon was ever scheduled, resulting in a failure to provide timely dental services as recommended.
Care plan meetings were not held or documented as required, and one resident’s care plan was not updated for new dentures
Penalty
Summary
The facility failed to include residents in care plan meetings and failed to ensure care plans were reviewed at least quarterly. Resident #71 stated during interview that she had not been invited to attend care plan meetings. Her record showed a care plan meeting on 03/13/25 in which she participated, but no further care plan meetings were documented after that date. The Social Worker confirmed that 03/13/25 was the last care plan conference held for this resident and stated she was behind on holding resident care plan meetings. The facility also failed to revise Resident #71's care plan after she was fitted for an upper denture and was awaiting its arrival. Her comprehensive care plan still reflected that she was at risk for oral/dental problems related to being edentulous and that she chose not to wear dentures. Resident #9 stated she had not been invited to care plan meetings, and her record contained no documented invitations or attendance since admission. Resident #88 likewise stated he had not been invited to or participated in quarterly care plan meetings, although the electronic record showed participation on 03/27/25 and 03/05/26. The Director of Social Services stated she was the only social worker for 90 residents and was behind on care plan meetings.
Improper POST Form Consent for Resident Without Capacity
Penalty
Summary
The facility failed to obtain consent from the resident’s representative on the POST form for Resident #11, instead allowing the form to be signed by the resident even though the resident did not have capacity at the time of consent. Resident #11 had diagnoses of vascular dementia, major depressive disorder, hallucinations, unspecified mood disorder, and anxiety. The medical record showed that a Virginia POST form was completed and signed by the resident selecting CPR with full treatment, and on the same date a physician determined that the resident did not have capacity to make medical decisions and that a medical power of attorney representative or surrogate decision-maker may make medical decisions regarding life-prolonging intervention or mental health treatment. During surveyor review, the Nursing Home Administrator stated that the Director of Admissions oversaw POST forms, and the Director of Admissions acknowledged the error when shown the POST form and the physician’s capacity determination.
Failure to Document NOMNC Delivery to Representative
Penalty
Summary
The facility failed to provide documentation that the Notice of Medicare Non-Coverage (NOMNC) was delivered to a resident representative for one of two residents sampled for beneficiary notification. For Resident #101, the NOMNC dated 11/26/25 indicated that Social Services called the resident representative on 11/24/25, but the form was signed by only one facility representative. During interview, the Director of Social Services confirmed that the NOMNC was completed verbally over the phone with only one staff signature, and stated that best practice is to have two signatures. She also stated she could not provide documentation that the NOMNC was mailed to the resident representative because the facility does not use certified mail and there was no documentation in the medical record showing that mailing occurred.
PASRR Not Updated for New Mental Health Diagnoses
Penalty
Summary
The Pre-admission Screening and Resident Review (PASRR) was not updated for a resident after new mental health diagnoses of Post-Traumatic Stress Disorder (PTSD) and Major Depressive Disorder were identified during the stay. The resident had been admitted with mental health-related diagnoses including auditory hallucinations and anxiety disorder, and a physician determined the resident did not have decision-making capability for health care decisions. The resident’s PASRR was most recently completed by the facility and listed anxiety, depression, and auditory hallucinations under current diagnoses. After the resident later acquired PTSD and Major Depressive Disorder, the PASRR was not updated and submitted for Level II review. During interview, the NHA stated the PASRR was usually completed by either the Director of Admissions or the Director of Social Services, and both the Director of Admissions and the Director of Social Services confirmed the PASRR needed to be updated for the new diagnoses.
Failure to Provide Daily Ambulation Assistance After Therapy Discharge
Penalty
Summary
The facility failed to ensure a dependent resident received services to maintain her gained level of independence with ADLs after therapy ended. Resident #9 stated she was supposed to walk daily with nursing staff after discharge from therapy but had only walked once. Record review of walking tasks for April, May, and June 2026 showed she walked with nursing staff only one time in the last three months. The Physical Therapy discharge note dated 04/24/26 documented recommendations for daily transfers to a wheelchair with nursing assistance and ambulation with a rolling walker and nursing assistance with a wheelchair follow as tolerated. The discharge note also showed Resident #9 was able to ambulate 65 feet with a rolling walker and contact guard assist with fair balance. Staff interviews confirmed nursing staff would be expected to walk her daily based on therapy recommendations, yet NA #52 and NA #70 reported they did not assist her regularly and had never seen her walk, while CNA #76 stated she could walk with touching assistance about 20 feet and got up daily. The DON confirmed the documentation showed Resident #9 had only walked once with nursing staff since therapy discharge.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store and label medications in accordance with accepted standards of practice. During a medication cart inspection with an LPN, a Humalog Insulin Kwikpen for Resident #9 was found in the west wing medication cart with an opening date of 05/10/26 and a use-by date of 06/10/26 written on the label, even though the pen remained in the cart on 06/24/26. The LPN confirmed the insulin pen should have been discarded. Resident #9’s physician orders showed the Humalog sliding scale coverage had been discontinued on 05/22/26, although the resident continued to have fingerstick blood glucose checks twice daily and could have required insulin coverage for an extremely high reading. During inspection of the east wing medication refrigerator with another LPN, a multi-use vial of tuberculin purified protein derivative (PPD) was found without a date indicating when it had first been opened. The vial label showed it had been delivered by the pharmacy on 06/01/26, but it had not been dated when first accessed. The LPN confirmed the vial had not been dated when first opened but should have been dated. The facility policy stated that when a vial is opened, the nurse should record the opened date on the vial, and the PPD prescribing insert stated that a vial entered and in use for 30 days should be discarded.
Failure to Continue CPR Until EMS Arrival for Full Code Resident
Penalty
Summary
The facility failed to ensure that Cardio-Pulmonary Resuscitation (CPR) was initiated and continued for a resident with a Full Code status who was found unresponsive and without vital signs. The resident had a documented Physician Orders for Scope of Treatment (POST) form indicating the desire to receive CPR in the event of cardiac or respiratory arrest. Despite this, staff members started CPR but discontinued it prior to the arrival of emergency medical services (EMS). On the night of the incident, an LPN and a nurse aide discovered the resident unresponsive during a routine check. They reportedly performed three to four rounds of CPR but stopped several minutes before EMS arrived. The nurse aide left the room to answer another resident's call light, and the LPN did not continue resuscitation efforts. The crash cart was obtained, and 911 was called, but CPR was not maintained until EMS took over, as required by the facility's policy and the resident's code status. The facility's investigation confirmed that the staff did not follow the established CPR policy, which mandates that CPR be provided and continued until EMS arrives unless there are obvious signs of irreversible death. Written statements from staff and interviews corroborated that CPR was stopped prematurely, and the responsible staff members were subject to disciplinary action. The deficiency resulted in the death of the resident and had the potential to affect all residents with a Full Code status.
Failure to Provide Adequate Supervision During Shower Results in Resident Injury
Penalty
Summary
The facility failed to provide adequate supervision to prevent avoidable accidents, resulting in harm to a resident. The incident occurred when a nursing assistant was showering a resident with a history of falls, poor safety awareness, impulsive movements, and diagnoses including epilepsy, early onset dementia, altered mental status, and muscle weakness. While the resident was lying on a shower bed, the nursing assistant lowered the bed rail and turned away to place a blanket on a nearby chair. During this time, the resident sat up and slid off the shower bed, falling to the floor and striking her head. The fall resulted in a laceration and hematoma to the resident's head, requiring emergency room treatment and sutures. The resident's care plan included multiple interventions to prevent falls, such as bed in the lowest position, fall mats, hip protectors, and ensuring the environment was free of hazards. However, these interventions were not followed in the shower room, as the bed rail was lowered and the resident was left unsupervised, directly leading to the accident and injury.
Scorched Beans Served to Residents
Penalty
Summary
The facility failed to provide palatable food by serving scorched beans to residents. During observation, the beans were noted to have a strong smoky smell and contained small bits of black burnt substance. Upon tasting, the beans had an overcooked, burnt flavor. The Culinary Account Manager confirmed that the beans had been scorched during preparation and acknowledged that the cook had scraped the bottom of the pan, resulting in the burnt product being served. This deficiency was identified as a random opportunity of discovery and had the potential to affect a limited number of residents in the facility.
Failure to Maintain Infection Control Practices and Equipment Integrity
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple observed lapses during medication administration and equipment maintenance. Nursing staff were observed placing multi-dose medication containers and their packaging directly on resident surfaces, such as overbed tables and bedside tables, without using barriers. These items were then returned to the medication cart, creating a risk for cross-contamination. Staff also placed medication containers on the edge of sinks and on top of the medication cart without barriers. Interviews confirmed that staff understood the risk of transferring infectious agents but did not consistently use barriers, and the Director of Nursing acknowledged that while it was standard practice to use barriers, there was no written policy in place to support this practice. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for a resident with pressure ulcers, as required by facility policy. The resident did not have an order for EBP, nor was there signage on the door to indicate the need for these precautions. Furthermore, two residents were observed using wheelchairs with rips and tears in the plastic coverings, exposing the inner padding, which staff acknowledged could not be adequately cleaned to prevent infection. These findings demonstrate a lack of adherence to infection control protocols and failure to maintain equipment in a condition that supports infection prevention.
Failure to Provide Required Medicare Coverage and Liability Notices
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) and Notification of Medicare Non-Coverage (NOMNC) forms to two residents who were reviewed for beneficiary protection notification practices. For one resident, there was no evidence that either the SNF ABN or NOMNC forms were provided or signed prior to the last covered day of Medicare Part A skilled services for both occupational and physical therapy. Discharge summaries indicated that therapy services ended because the resident had achieved the highest practical level or met all goals, but the required notifications were not issued. Staff interviews confirmed that the social worker was not made aware by therapy that the resident was at maximum potential and would be completing services, resulting in the failure to provide the necessary forms. For another resident, the required NOMNC form was not issued prior to the last covered day of Medicare Part A services, as confirmed by a review of the electronic medical record and staff interviews. Therapy discharge summaries indicated that all goals were met or the highest practical level was achieved, but the social worker was unaware that the NOMNC needed to be presented due to the resident's decision to go home. The therapy manager confirmed that the resident was discharged from services after meeting maximum potential, but the required notification was not provided.
Failure to Implement Wound Care Recommendations for Pressure Ulcer Management
Penalty
Summary
The facility failed to implement recommendations made by the wound care service for a resident with pressure ulcers. The wound care service had recommended the addition of modular protein and a multivitamin with zinc supplements to the resident's care plan, as documented in a progress note. However, a review of the resident's orders showed that these supplements were not added, and there was no documentation explaining the omission. The DON confirmed that there was no information in the chart regarding the absence of the modular protein and noted that the facility's physician typically does not order the multivitamin with zinc and vitamin C. The resident reported having pressure ulcers that seemed to be improving but was unaware of how they developed.
Failure to Schedule Oral Surgery Following Dental Referral
Penalty
Summary
The facility failed to provide necessary dental services for a resident by not scheduling oral surgery in a timely manner as recommended by the dentist. The resident was observed to have broken and missing teeth, and the care plan identified a risk for oral/dental health problems, requiring staff assistance with oral care and dental consults as needed. A dental exam summary recommended extraction of all remaining teeth and included a referral to an oral surgeon. Nursing documentation confirmed a referral was to be sent to a specific facial surgeon, with instructions to seek another oral surgeon if the first would not accept the resident. However, an LPN who previously worked in medical records reported being unable to find any information confirming that an appointment with an oral surgeon was ever made, indicating a lapse in follow-through on the dental referral.
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Illustrative
What surveyors actually found near you
We read the 104 citations issued within 25 miles in the last 12 months — including the 1 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Danville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Trinity Health Care Of Logan | 15.3 mi | ★★★★★ | 23 | 0 |
| Logan Center | 16.9 mi | ★★★★★ | 0 | 0 |
| Marmet Center | 18.8 mi | ★★★★★ | 19 | 0 |
| Valley Center | 18.8 mi | ★★★★★ | 25 | 0 |
| Lincoln Healthcare Center | 20.1 mi | ★★★★★ | 0 | 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 August 2026) and official state health department websites.