Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
HILLCREST CARE CENTER
WRAY, CO · 45 certified beds · Last Life Safety survey October 3, 2024
CMS Certification Number 065316 · first certified January 1994
Ownership
Independently operated (no chain recorded by CMS) · Government - Hospital district
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within CO
23 citations — more than 68% of the 210 certified nursing homes in CO. Compared within CO rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 5 citations; the earlier surveys in the window averaged 9. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: March 2026 to October 2026. This facility’s last Life Safety survey was October 2024. Facilities in CO are typically surveyed 17–24 months after the last one (median 19), measured over 177 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
13 of the 23 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
6 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 23 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0908 Keep all essential equipment working safely.
- F-0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
How that compares
Compared with the median facility in CO, and nationally. Surveyors differ markedly between states, so the CO figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 23 |
| Median facility in CO | 16 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| December 16, 2021 | 6 |
| March 30, 2023 | 12 |
| October 3, 2024 | 5 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| E-0039 | Conduct testing and exercise requirements. | 2 | 2023-03-30 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2024-10-03 |
| K-0324 | Provide properly protected cooking facilities. | 1 | 2021-12-16 |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 1 | 2021-12-16 |
| E-0029 | Develop a communication plan. | 1 | 2023-03-30 |
| E-0015 | Address subsistence needs for staff and patients. | 1 | 2023-03-30 |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | 1 | 2023-03-30 |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | 1 | 2021-12-16 |
What the citations cover
- Emergency Preparedness Deficiencies 13
- Gas, Vacuum, and Electrical Systems Deficiencies 4
- Services Deficiencies 2
- Smoke Deficiencies 2
- Other 2
| Category | Citations |
|---|---|
| Emergency Preparedness Deficiencies | 13 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 4 |
| Services Deficiencies | 2 |
| Smoke Deficiencies | 2 |
| Egress Deficiencies | 1 |
| Miscellaneous Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
October 3, 2024 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (November 18, 2024) |
| K-0522 | Have an externally vented heating system. | Deficient, Provider has date of correction (November 19, 2024) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (October 23, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (October 22, 2024) |
| K-0923 | Have proper medical gas storage and administration areas. | Deficient, Provider has date of correction (November 15, 2024) |
March 30, 2023 — 12 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0001 | Establish an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (April 27, 2023) |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (April 27, 2023) |
| E-0009 | Include a process for Emergency Preparedness collaboration. | Deficient, Provider has date of correction (April 27, 2023) |
| E-0013 | Develop Emergency Preparedness policies and procedures. | Deficient, Provider has date of correction (April 27, 2023) |
| E-0015 | Address subsistence needs for staff and patients. | Deficient, Provider has date of correction (April 27, 2023) |
| E-0023 | Establish policies and procedures for medical documentation. | Deficient, Provider has date of correction (April 27, 2023) |
| E-0024 | Establish policies and procedures for volunteers. | Deficient, Provider has date of correction (April 27, 2023) |
| E-0026 | Establish roles under a Waiver declared by secretary. | Deficient, Provider has date of correction (April 27, 2023) |
| E-0029 | Develop a communication plan. | Deficient, Provider has date of correction (April 27, 2023) |
| E-0036 | Establish emergency prep training and testing. | Deficient, Provider has date of correction (April 27, 2023) |
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (April 27, 2023) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (April 27, 2023) |
December 16, 2021 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (January 12, 2022) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (January 29, 2022) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (January 24, 2022) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (January 29, 2022) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (January 27, 2022) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (January 29, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.