Hillcrest Manor Sanitarium

Emergency Preparedness Deficiencies

Implement emergency and standby power systems.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Nursing and Physician Services Deficiencies

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Nursing and Physician Services Deficiencies

Ensure that the resident and his/her doctor meet face-to-face at all required visits.

Pharmacy Service Deficiencies

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Smoke Deficiencies

Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.

Miscellaneous Deficiencies

Meet fire sprinkler requirement for tall buildings.

Environmental Deficiencies

Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.

Environmental Deficiencies

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Egress Deficiencies

Have corridors or aisles that are unobstructed and are at least 8 feet in width.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Emergency Preparedness Deficiencies

Implement emergency and standby power systems.

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Nursing and Physician Services Deficiencies

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Emergency Preparedness Deficiencies

Address subsistence needs for staff and patients.

Emergency Preparedness Deficiencies

Provide emergency officials' contact information.

Emergency Preparedness Deficiencies

Conduct testing and exercise requirements.

Environmental Deficiencies

Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.

Environmental Deficiencies

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Smoke Deficiencies

Properly install and monitor supervisory attachments on automatic sprinkler systems.

Nursing and Physician Services Deficiencies

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Nutrition and Dietary Deficiencies

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Resident Assessment and Care Planning Deficiencies

Assess the resident when there is a significant change in condition

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Have properly installed hallway dispensers for alcohol-based hand rub.

Smoke Deficiencies

Install an approved automatic sprinkler system.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

Services Deficiencies

Install properly constructed and protected linen or trash chutes.

Miscellaneous Deficiencies

Provide a written emergency evacuation plan.

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Miscellaneous Deficiencies

Have restrictions on the use of highly flammable decorations.

Gas, Vacuum, and Electrical Systems Deficiencies

Meet requirements for the use of electrical equipment.

Environmental Deficiencies

Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.

Environmental Deficiencies

Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.