Hillcrest Center

Inspectors wroteBased on review of facility policy, review of clinical record, review of facility documentation, and staff interview, it was determined that the facility failed to notify the resident representative of a transfer to the hospital for one of one resident reviewed for notification of changes (Resident R1).

Inspectors wroteBased on review of clinical records, and staff interview it was determined that the facility failed to ensure care and services were provided in accordance with physician orders for one of one resident reviewed (Resident R1).

Inspectors wroteBased on review of facility policy, review of facility documentation, review of clinical records, and staff interview it was determined that the facility failed to maintain complete and accurate documentation one of two residents reviewed (Resident R1).

Inspectors wroteBased on review of clinical records, hospital records, and staff interviews, it was determined the facility failed to appropriately monitor and notify the physician of repeated critically elevated blood pressure readings and failed to ensure an anti-hypertensive medication was administered as ordered by the physician. This failure resulted in actual harm to Resident R12 who sustained uncontrolled hypertension, transferred to the hospital with a diagnosis of hypertensive urgency requiring hospital admission for one of 30 residents reviewed. (Resident R12)

Inspectors wroteBased on observation, clinical record review and staff interview, it was determined that the facility failed to ensure that supervision was provided to one of 30 residents reviewed (Resident R4) and the safe temperature of hot beverages in one of three nursing floors (Third Floor)

Inspectors wroteBased on observation, clinical record review, staff interview and review of professional medical information, it was determined that the facility failed to ensure that four of four licensed nursing staff were knowledgeable in stoma/colostomy care. (Employees E5, E6, E7, and E10)

Inspectors wroteBased on observation and review of facility policy, it was determined that the facility failed to ensure that medications were properly stored and disposed on two of three nursing units. (1st and 3rd floors)

Inspectors wroteBased on review of facility policy, review facility documentation, review of clinical records, observations, and staff interviews, it was determined that the facility failed to ensure residents with limited range of motion received treatment and services to maintain or improve range of motion/mobility for one of three residents reviewed with limited range of motion (Resident R93). Findings Include: Review of facility policy Restorative Nursing revised August 7, 2023, revealed restorative programs are coordinated by nursing or in collaboration with rehabilitation and are patient specific based on individual patient needs. [...]

Inspectors wroteBased on review of facility policy, observations, and staff interviews it was determined that the facility failed to maintain infection control practices related to collection and transport of biohazards on one of three nursing units (2nd floor). Findings Include: Review of facility policy Collection and Transport of Specimens revised March 20, 2026, revealed that specimen collection items are kept in a separate area away from food, medications, and other items. Observations on April 13, 2026, at 10:20 a.m. revealed consultant lab tech, Employee E19, was holding a biohazard specimen transport pouch with a vial of blood enclosed in the bag. Lab tech, Employee E19, proceeded to hold the biohazard specimen pouch inside a cooler filled with ice [located at the 2nd floor nurses station] and used the ice scoop to pour ice into the biohazard specimen pouch enclosed with a vial of blood. [...]

Inspectors wroteBased on review of facility policy, review of facility documentation, review of grievances, and interviews with residents and staff, it was determined that the facility failed to ensure a sanitary, and homelike environment for one of three nursing units (2nd floor)

Inspectors wroteBased on observation and resident interview, the facility failed to ensure that the environment remains free of pest for one on three dining rooms. (3rd floor)

Inspectors wroteBased on observation, review of facility documentation, review of facility's policy and residents and staff interviews, it was determined that the facility failed to maintain an effective pest control program to ensure that the building was free of rodents.

Inspectors wroteBased on review of clinical records, facility policy, dietary guidelines, and interview with staff, it was determined the facility failed to ensure Resident R369 was provided food items congruent with his/her dysphagia diet. This failure resulted in actual harm to Resident R369 who was able to obtain food items incongruent with his/her dietary restrictions, experienced a choking episode, requiring Cardio Pulmonary Resuscitation (CPR), and transfer to the hospital for one of 33 reviewed (Resident R369).

Inspectors wroteBased on interview with staff and review of facility provided documentation, it was determined facility did not notify Long Term Care State Ombudsman of facility-initiated discharges for two of six months reviewed. (November 2024 and December 2024)

Inspectors wroteBased on observations, interview with staff and review of facility provided documentation, it was determined that facility did not ensure to maintain infection control and prevention practices on one of three units observed (1st floor unit)

Inspectors wroteBased on interview with resident and staff, review of facility provided documentation, and review of clinical record, it was determined that facility did not provide reasonable accommodations related to phone services for one of 33 residents reviewed. (Resident R149)

Inspectors wroteBased on clinical record reviews, interviews with staff and reviews of policies and procedures, it was determined that the interdisciplinary care team failed to update or revised the care plan for activities of daily living for one of two residents reviewed. ( Resident R90)

Inspectors wroteBased on observations of care and services, clinical record reviews, and interviews with staff, it was determined that the facility failed to ensure that a physician's order was obtained, for the use of resident care adapted equipment for one of two residents reviewed. (Resident R151) Findings iclude: Review of Resident R151's quarterly Minimum Data Set (MDS- assessment of resident's needs) dated April 22, 2025 revealed that the resident only sometimes responded adequately to simple directions and had severe cognitive impaired. Continued review of the MDS revealed that the resident was functionally impaired on one side with the upper body extremity (shoulder, elbow, wrist and hand) and totally dependent on staff assistance for eating, personal hygiene and putting on and taking off foot wear. Clinical record review indicated that Resident R151 had diagnoses that included: [...]

Inspectors wroteBased on review of clinical records, staff and resident interviews, it was determined that the facility failed to provide culturally competent, trauma informed care in accordance with professional standards of practice, accounting for the resident's past experiences and preferences in order to eliminate and/or mitigate triggers that may cause re-traumatization of the resident for one of 33 residents sampled (Resident R 73)

Inspectors wroteBased on clinical record review, interviews with staff and residents, reviews of policies, procedures and facility documentation, investigation, it was determined that that facility staff failed to immediately report an allegation of resident verbal and physical abuse for one of fourteen residents reviewed. Resident R1)

Inspectors wroteBased on the review of clinical records, facility documentation, interview with staff, it was determined that the facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to the care of residents with PICC line ( a tube placed in a large vein in the neck, chest, groin, or arm to give fluids, blood, or medications or to do medical tests quickly) for two of four employee records reviewed. (Employee E8 and E9). Findings Include: Observation of Resident R137 on July 25, 2024, at 10:22 a.m., revealed that the resident had a right upper extremity PICC line insertion. There was documentation on the dressing to indicate the date and time the dressing last changed was July 18, 2024. Review of clinical record for Resident R13 revealed that the resident was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observations, review of facility policies, review of facility documentation, review of clinical records, and staff interviews, it was determined that the facility failed to establish an effective infection control program related to infection surveillance, catheter care, and use of personal protective equipment with transmission-based precautions for one of three nursing units observed (2nd floor). Findings Include: Review of facility policy COVID-19 revised July 1, 2024, revealed in addition to standard precautions, special contact and droplet precautions will be implemented for residents confirmed to have COVID-19 based on the Centers for Disease Prevention & Control (CDC) guidance. Further review of facility policy revealed staff will follow the patient specific PPE signage. Review of Infection Control Guidance: [...]

Inspectors wroteBased on a review of facility documentation, facility policies and staff interviews, it was determined that the facility failed to maintain an effective antibiotic stewardship program that includes a system that includes antibiotic use protocols and a system to effectively monitor antibiotic usage for five of five months of antibiotic stewardship program data reviewed. (February 2024, March 2024, April 2024, May 2024 and June 2024). Findings Include: Review of facility policy Antibiotic Stewardship dated August 7, 2024 , revealed that Centers will implement an Antibiotic Stewardship Program (ASP) that includes antibiotic use protocols and systems for monitoring antibiotic use. The Infection Preventionist (IP) is responsible for the Infection Prevention and Control program including ASP. The Administrator is ultimately responsible for the overall compliance with the ASP. [...]

Inspectors wroteBased on the review of facility provided documentation and interview with staff, it was determined that facility did not ensure to include as part of its Quality Assurance and Performance Improvement (QAPI) program mandatory training that outlines and informs staff of the elements and goals of the facility's QAPI program for four of five employees reviewed (Employees E10, E11, E12 and E13)

Inspectors wroteBased on review of clinical records and resident and staff interviews, it was determined that the facility failed to ensure medications were administered per physician orders for one of 34 residents reviewed (Resident R68). Findings Include: Review of Resident R68's Quarterly Minimum Data Set (MDS - federally mandated resident assessment and care screening) dated June 28, 2024, revealed the resident was cognitively intact and had a diagnosis of urinary tract infection (an infection in any part of the urinary system) in the last 30 days. Review of Resident R68's comprehensive care plan revised August 30, 2023, revealed the resident was at risk for alterations in comfort related to impaired mobility and skin breakdown. Interventions included to medicate resident as ordered for pain. [...]

Inspectors wroteBased on observations, review of clinical records, facility policies and procedures, and interviews with staff and resident, it was determined that the facility failed to provide adequate treatment and care for a PICC (Peripherally Inserted Central Line Catheter) in accordance with professional standards of practice for one of one resident with PICC line reviewed (Resident R137).

Inspectors wroteBased on interviews and the review of clinical records, it was determined that the facility failed to ensure that a medication was available in a timely manner for 1 out of 34 residents reviewed (Resident R135).

Inspectors wroteBased on the review of clinical records, interviews with resident and staff, it was determined that the facility failed to ensure that residents drug regimen was free of unnecessary drugs related to the use of antipsychotic medication without adequate monitoring for two of five residents reviewed for drug regimen. (Resident R45 and Resident R29) Findings Include: Review of facility policy, Medication Management, dated January 2024, revealed that Each resident's drug regimen is reviewed to ensure it is free from unnecessary drugs. This includes any drug In excessive dose (including duplicate drug therapy): for excessive duration; without adequate monitoring: without adequate indications for its use; in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or . any combination of these reasons. [...]