Hillcrest Care Center Inc

Inspectors wroteBased on observation and interview, the facility failed to ensure the dumpster was maintained to keep pest out and/or to keep garbage contained in the dumpster. This deficient practice had the potential to affect all residents in the facility. The facility was 81. The facility did not provide a policy for maintaining the dumpster. Observations on 01/19/26 at 10:05 A.M., and 1:00 P.M., of the outside trash dumpster showed;- Each dumpster lid was open with visible garbage bags, boxes, and other miscellaneous debris inside. Observations on 01/20/26 at 11:24 A.M., and 2:02 P.M., 1/21/26 at 8:22 A.M., 11:44 A.M., and on 01/22/26 at 8:14 A.M., and 10:11 A.M., of the outside trash dumpster showed:- The left-side dumpster lid was open with visible garbage bags, boxes, and other miscellaneous debris inside. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to treat residents with dignity and respect when staff stood over three residents (Residents #21, #33, and #36) and fed the residents during meals and left one resident (Resident #80) with no privacy and exposed during his/her wound care, out of 18 sampled residents. The facility census was 81. Review of the facility's policy titled, Resident Rights, undated, showed:- Each resident shall be treated with consideration, respect a full recognition of his/her dignity and individuality, including privacy in treatment and care of his/her personal needs. 1. Observation on 01/20/26 at 12:07 P.M., of the main dining room showed:- Certified Nursing Assistant (CNA) N stood over and fed Resident #36 during the noon meal. [...]

Inspectors wroteBased on interview and record review, the facility failed to issue a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) to the resident and/or the resident's representative in writing at least two calendar days before discharge from skilled services. This notice informs the beneficiary about potential non-coverage and the option to continue services with the beneficiary accepting the financial liability for those services. This practice affected two residents (Residents #43 and #100) out of three sampled residents. The facility census was 81. The facility did not provide a policy regarding SNF ABN forms. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 81. The facility did not provide a homelike environment policy. Observations on 01/19/2026 at 10:34 A.M., 01/20/2026 at 6:00 P.M., 01/21/2026 at 11:35 A.M., and 01/22/26 at 11:21 A.M., of the nurse's station area, showed: - One ceiling fan over the cafe area with a buildup of dirt and debris; - Two ceiling fans over the bird cage area with a buildup of dirt and debris and missing fan blades; - Two skylight (roof installed window) outer edges over the cafe area with a buildup of dust and debris; - Two skylight outer edges over the nurses' station with a buildup of dust and debris. Observation on 01/19/2026 at 12:34 A.M. [...]

Inspectors wroteBased on interview and record review, the facility failed to document, obtain a signature, and/or send notification in writing to the resident and/or the resident's representative of a transfer or discharge to a hospital, including the statement of appeal rights or the name, address, or the telephone number of the Office of the State Long Term Care Ombudsman (advocate for the resident in nursing facilities) within the transfer and discharge notices and bed-hold policy (the holding or reserving a resident's bed while the resident is absent from the facility for therapeutic leave or hospitalization) for four residents (Residents #3, #5, #19 and #34) out of five sampled residents. The facility census was 81. The facility did not provide a transfer/discharge policy. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff used acceptable infection control procedures and practices for wound care for four residents (Residents #1, #19, #51 and #80) out of five sampled residents. The facility also failed to ensure ice chest carts were monitored to prevent access to residents and visitors without staff assistance for two residents (Residents #14 and #77) outside the sample. These deficient practices could potentially affect all residents. The facility census was 81. Review of the facility's policy titled, Enhanced Barrier Precautions (EBP) to Infection Control Guidance, dated March 2024, showed:- To prevent broader transmission of multidrug resistance organisms (MDRO) and to help protect residents with chronic wound and indwelling devices. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure 26 residents out of 27 sampled residents (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25 and #26) were free of misappropriation of their property when Bookkeeper A utilized resident trust accounts and resident cash for his/her own personal use totaling $20,110. The facility census was 84. The administration was notified on 03/28/25 of the Past Non-Compliance which occurred between 02/06/25 through 02/10/25. On 02/06/25, upon notification, the facility administrator started an investigation, notified the police department and the Department of Health and Senior Services of the misappropriation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean and comfortable homelike environment. This deficient practice had the potential to affect all residents in the facility. The facility census was 80. The facility did not provide a homelike environment policy. 1. Observations on 10/21/24 at 12:11 P.M.,10/22/24 at 10:41 A.M., and 10/23/24 at 10:54 A.M., of the screened-in designated smoking area showed: - Several dead insects and bird droppings lay on top of several two-by-four wood shelf supports; - A buildup of cigarette ashes in the cracks and crevices on the floor; - Scattered cigarette butts, leaves, and dirt lay on the floor; - A N95 (respiratory protective device) mask lay on the floor; - A broom lay against the brick column near the smoking receptacle. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to a hospital, including the reasons for transfer for four residents (Residents #7, #20, # 46 and #279) out of four sampled residents. The facility's census was 80. The facility did not provide a transfer/discharge policy. 1. Review of Resident #7's medical record showed: - The resident transferred to the hospital on [DATE], and was readmitted to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and was readmitted to the facility on [DATE]; - No documentation of written notification to the resident and/or the resident's representative of the resident's transfer to the hospital on [DATE] and 08/17/24. 2. Review of Resident #20's medical record showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of their bed hold policy at the time of transfer to the hospital for four residents (Residents #7, #20, #46, and #279) out of four sampled residents. The facility census was 80. The facility did not provide a bed hold policy. 1. Review of Resident #7's medical record showed: - The resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - The resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; - No documentation the resident and/or the resident's representative was informed in writing of the facility's bed hold policy at the time of the transfers. 2. Review of Resident #20's medical record showed: - The resident transferred to the hospital on [DATE], and readmitted to the facility on [DATE]; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to document the type, the stage, the measurements, and the characteristics of the facility acquired injury for two residents (Residents #38 and #46) out of two sampled residents. The facility census was 80. Review of the policy titled, Pressure Ulcer, Care and Prevention of, undated, showed: - The purpose of this policy is to prevent and treat further breakdown of pressure sores; - The nurse is responsible for carrying out the treatment as ordered by the attending physician and for implementing measure to prevent pressure ulcers; - Observe skin. Any persistent reddened area that remains after pressure is relieved is a high risk area to a pressure ulcer to begin. 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide documentation of communication between the facility and the dialysis (a process for removing waste and excess water from the blood) center for two residents (Residents #6 and #32) out of two sampled residents and one resident (Resident #11) outside the sample. The facility census was 80. Review of the facility's policy titled, Dialysis, Care of a Resident Receiving, undated, showed: - Care of the arteriovenous (AV) shunt/fistula/graft (a surgically created connection between an artery and a vein used for hemodialysis): keep the area clean and dry; feel for the thrill (a palpable murmur that feels like a ringing phone) sensation daily; inspect the access site for redness, swelling, or warmth; watch for bleeding after dialysis; monitor signs of infection; checking the thrill sensation; [...]

Inspectors wroteBased on interview and record review, the facility failed to conduct at least twelve hours of nurse aide in-service education per year and failed to provide the required annual competencies of Dementia Care (care of a resident with an impaired ability to remember, think, or make decisions) of two nurse aides sampled. The facility census was 80. The facility did not provide a nurse aide in-service education policy. Review of the facility assessment, revised September 2024, showed: - Required in-service training for nurse's aides: 1. Be sufficient to ensure the continuing competence of nurse aides, but must be no less than 12 hours per year; 2. Include dementia management training and resident abuse preventions training; 3. Address areas of weakness as determined by the facility assessment and address the special needs of residents to as determined by the facility staff; 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate supervision to ensure the safety of one resident (Resident #1). On 08/01/24 at 3:00 A.M., the facility failed to initiate a search for Resident #1 and implement the facility policy for missing residents when staff noticed the resident's call light on, but the room was empty. On 08/01/24 at 6:45 A.M., during morning medication pass, staff noted Resident #1 was not in his/her room. The staff finished the medication pass and reported to the charge nurse. On 08/01/24 at 8:00 A.M., the staff began searching for the resident and found the resident outside lying on the ground in the courtyard. The resident fell down outside in the late evening on 07/31/24, and lay on the ground until 08/01/24 at 8:15 A.M. The facility census was 84. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide resident care for activities of daily living (ADLs) when the residents did not receive a minimum of two showers per week for six residents (Resident #7, #26, #33, #48, #57, and #65) out of 18 sampled residents. The facility's census was 75. The facility did not provide a policy related to shower frequency. 1. Review of Resident #7's medical record showed: - An admission date of 04/30/22; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to control the fly population in the facility. This affected four residents (Resident #21, #24, #39, and #48) out of 18 sampled residents and two residents (Resident #55 and #76) outside the sample. The facility's census was 75. Review of the facility's undated Pest Control policy showed: - The facility will have a pest control contract which provides frequency treatment of the environment for pests and allow for additional visits when problem is detected; - Monitoring the environment will be done by the facility staff; - Pest control problems will be reported promptly. 1. Review of Resident #21's medical record showed: - admitted on [DATE]; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean and comfortable homelike environment. This had the potential to affect all residents. The facility's census was 75. The facility did not provide a policy. Observation on 08/23/23 at 09:58 A.M. showed missing corner bead from the floor to the ceiling in room [ROOM NUMBER] near bed one. Observation on 08/23/23 at 10:05 A.M. showed the privacy curtain between the residents' beds in room [ROOM NUMBER] with patches of light brown colored soiling along with dark brown splatter-like soiling at the bottom of the curtain. Observation of room [ROOM NUMBER] on 08/24/23 at 12:24 P.M. showed: - Corner bead and corner bead trim missing from floor to ceiling near bed one; - Approximately four feet of cove base missing from the interior wall. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and/or the resident's representative in writing of a transfer or discharge to a hospital, including the reasons for transfer for three residents (Resident #7, #24, and #71) out of 18 sampled residents. The facility's census was 75. Review of the facility's policy titled, Discharge/Transfer of Resident, undated, showed: - Purpose is to provide safe departure from the facility and to provide sufficient information for aftercare of the resident; - Notice of transfer or discharge to be provided as necessary; - Bed hold forms to be provided as necessary. 1. Review of Resident #7's medical record showed: - Transferred and admitted to the hospital on [DATE] and readmitted to the facility on [DATE]; [...]

Inspectors wroteBased on interview and record review, the facility failed to inform the resident and family or legal representative of their bed hold policy at the time of transfer to the hospital for three residents (Resident #7, #24, and #71) out of 18 sampled residents. The facility's census was 75. Review of the facility's policy titled, Discharge/Transfer of Resident, undated, showed: - Purpose is to provide safe departure from the facility and to provide sufficient information for aftercare of the resident; - Notice of transfer or discharge to be provided as necessary; - Bed hold forms to be provided as necessary. 1. Review of Resident #7's medical record showed: - Transferred and admitted to the hospital on [DATE] and readmitted to the facility on [DATE]; - No documentation that the resident's representative was informed in writing of the facility bed hold policy at the time of transfer. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement a care plan with specific interventions to meet individual needs for two residents (Resident #23 and #71) out of 18 sampled residents. The facility's census was 75. Review of the facility's policy titled, Care Plan Comprehensive, undated, showed: - An individualized comprehensive care plan that includes measurable goals and timeframes will be developed to meet the resident's highest practicable physical, mental, and psychosocial well-being; - The comprehensive care plan will be based on a thorough assessment that includes, but is not limited to, the MDS (Minimum Data Set - a federally mandated assessment completed by the facility); - The interdisciplinary care plan team is responsible for the periodic review and updating of care plans when a significant change in the resident's condition has occurred; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to label and store medications in a safe and effective manner. This had the potential to affect all residents, including Resident #25, #28, #30, #31, #44, #52, #69, and #100. The facility's census was 75. Review of the facility's policy titled, Medications, Storage Of, undated, showed: - Drugs must be stored at appropriate temperature levels. Drugs stored in a refrigerator must be stored between 36 and 46 degrees Fahrenheit (F); - No discontinued, outdated, or deteriorated drugs or biologicals may be retained for use. All such drugs must be returned to the issuing pharmacy or destroyed in accordance with established guidelines; - All controlled substances must be stored under double lock and key. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide and document that residents received or declined appropriate immunizations and failed to provide and document pertinent education to residents or residents' representative regarding benefits, side effects or warnings of those immunizations for two residents (Resident #57 and #61) out of five sampled residents. The facility's census was 75. The facility did not provide a policy on immunizations. 1. Review of Resident #57's medical record showed: - admission date of 01/27/21; - Diagnoses of Type ll Diabetes Mellitus (a chronic condition that affects the way the body processes sugar), Congestive Heart Failure (CHF, a chronic condition in which the heart doesn't pump blood as well as it should) and Chronic Obstructive Pulmonary Disease (COPD, a group of lung diseases that block airflow and make it difficult to breathe); [...]