Hillcrest Manor Sanitarium

In the surveyor’s words

From the most serious findings on record at Hillcrest Manor Sanitarium, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Feb 15, 2024

  Based on observation, interview and record review, the facility failed to implement an emergency plan for food preparation when the kitchen ceiling had water damage. This failure had the potential for contamination of food for 57 residents. Findings: On 1/23/24, at 6:15 P.M., a concurrent observation was conducted with a Dietary Aide (DA 1) of the dining area. Several residents were in the dining room, some leaving the area. DA 1 stated the residents had just finished eating dinner. DA 1 stated the food preparation was done in the kitchen, but there was no leaking while the food was being prepared. On 1/23/24 at 6:25 P.M., the facility kitchen was toured with the Facility Owner (FO). Several areas of water damage were noted on the kitchen ceiling, including over the stove. […]

• No harm, potential for more than minimal, patternF727Feb 12, 2026

  Based on observation, interview, and record review, the facility failed to staff a Registered Nurse (RN) for at least eight hours a day for 19 days from July 1, 2025, through September 30, 2025. This failure may have prevented residents from receiving advanced care or having their complex medical needs managed effectively. Findings: A review of the PBJ (Payroll-Based Journal) Staffing Date Report and CASPER Report 1705 D, which help Skilled Nursing Facilities identify areas for improvement, showed that in Quarter 4 of 2025 (July 1-September 30), the facility triggered a No RN hours alert. This indicated there were at least four days in the quarter without any RN hours. […]

• No harm, potential for more than minimal, patternF812Feb 12, 2026

  Based on observation, interview, and record review, the facility failed to (1) check the consistency of the pureed (blended to a smooth and creamy consistency) foods for a resident and (2) ensure the beef patties were cooked according to the manufacturer's guidelines for 48 of 48 residents who received the beef patties. These failures could lead to food that was not palatable and texture that was not safe for a resident to consume. In addition, residents who consume the beef patties could contract food-borne illness.Findings: 1. On 2/11/26 at 11 A.M., an observation during a puree preparation and interview with [NAME] (CK) 1 was conducted. CK 1 poured water into the container of the blender, an amount not measured, and four scoops of thickener into the container of the blender. […]

• No harm, potential for more than minimal, patternF727Nov 21, 2024

  Based on observation, interview, and record review, the facility failed to staff a Registered Nurse (RN) for at least 8 hours a day for twelve days from April 1 - June 30, 2024. This failure had the potential to prevent residents from receiving the care they needed. Findings: Review of PBJ (Payroll-Based Journal) Staffing Data Report, CASPER Report 1705 (a report that can help Skilled Nursing Facilities identify areas for improvement in care and operations) for Quarter 3 2024 (April 1 - June 30) indicated that No RN hours was triggered for twelve days. On 11/20/24 at 9:30 A.M., an observation of current staffing was observed posted at nurse's station. […]

• No harm, potential for more than minimal, patternF760Nov 21, 2024

  Based on interview and record review, the facility failed to ensure the staff followed policy and procedure for one of 14 sampled residents (Resident 22) when: 1) the staff did not document the medication administration accurately and 2) the staff did not document the medication administration in a timely manner. As a result, there was a potential the residents did not receive the prescribed amount of medication. Findings: Resident 22 was admitted to the facility on [DATE] with diagnoses which included schizophrenia (a type of mental health illness) per the facility's Admission Face Sheet. 1) A review of records was conducted. The physician order dated, 6/20/24 indicated, Resident 22 was to receive eight units of insulin (a medication to control blood sugar) three times a day. […]