Hillcrest Health Care Center

Inspectors wroteBased on clinical record review, observation, staff interviews, and policy review, the facility failed to provide dignity to residents during personal care for 2 of 13 residents (Residents #1, #7). The facility reported a census of 50 residents. Findings Include: 1. Resident #1's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15/15 indicating normal cognition. The MDS documented the resident required partial/moderate assistance with toilet hygiene. The document indicated the resident was continent of bowel and bladder. The MDS revealed diagnoses of lymphedema, morbid obesity and other disorders of electrolyte and fluid imbalance. The Care Plan revised 4/3/26 identified the resident had self care deficits directing staff the resident required 2-4 staff for toilet transfers, and used disposable briefs. [...]

Inspectors wroteBased on record review, staff interviews and facility policy review the facility failed to complete skin assessments to include measurements and wound status for 2 of 3 residents (Resident #1 and #2) reviewed with pressure ulcers. The facility also failed to sign out wound treatment orders and being completed for 1 of 3 residents (Resident #1) reviewed with pressure ulcers. The facility reported a census of 50 residents.

Inspectors wroteBased on clinical record, observations, resident interviews, staff interviews, and policy review, the facility failed to provide respiratory care and services in accordance with professional standards of practice for 2 of 2 residents (Resident #12, #13) reviewed, requiring the use of oxygen. The facility failed to provide oxygen as documented in the physician orders. The facility reported a census of 50 residents.

Inspectors wroteBased on clinical record review, facility record review, resident and resident family interviews, staff interviews and facility policy the facility failed to appropriately implement interventions to protect 2 out of 3 residents (Resident #3 and #50) reviewed from abuse. The facility reported a census of 57 residents.

Inspectors wroteBased on Electronic Health Records (EHR) review, observations, resident interview, and staff interview the facility failed to provide the residents with a comfortable / clean homelike environment when bed linens were not applied to beds in a timely manner and rooms were not clean for 3 for 20 residents reviewed (Resident #17, #30 and #55). The facility reported a census of 57 residents.

Inspectors wroteBased on clinical record review, Medication Administration Records and Treatment Administration records (MAR-TAR) review, resident and resident family interviews, staff interviews and facility policy review the facility failed to provide physician ordered medications and failed to notify the physician of missed medications for 3 of 3 residents reviewed (Resident #7, #20 and #35) and the facility failed follow physician ordered interventions to notify the physician for a resident with weight fluctuations for 1 of 3 residents (Resident #10). The facility reported a census of 57 residents.

Inspectors wroteBased on observation, electronic health record (EHR) review, resident interview and staff interview the facility failed to provide nursing staff to assure residents safety by not responding to call lights in a timely manner for 3 of 16 resident reviewed (Resident #30, #32 and #33). The facility reported a census of 57 residents.

Inspectors wroteBased on observations, resident and staff interviews and policy review the facility failed to ensure proper temperatures for foods served to residents. The facility reported a census of 57 residents.1. The Minimum Data Set (MDS) dated [DATE] documented Resident #30 had a Brief Interview for Mental Status (BIMS) of 14 indicating no cognitive impairment. On 3/18/26 at 10:36 AM Resident #30 stated dinner meals are served cool. Resident #30 stated she does not ask the staff to reheat the food she just does not eat the food. Resident #30 explained the staff would not reheat the food if she asked. 2. The MDS dated [DATE] for Resident #33 documented a BIMS of 15 indicating no cognitive impairment. On 3/18/26 at 7:58 AM Resident #33 stated most meals are served cold. Resident #33 stated she eats most meals in her room. Resident #33 stated she would like the meals to be served warmer. [...]

Inspectors wroteBased on observation, clinical record review, and staff interview, the facility failed to implement proper hand hygiene protocols to prevent the spread of infection during the administration of oral medication, insulin administration, and enteral tube medication administration for 4 of 4 resident observed for medication administration (Residents #2, #16, #19 and #48). Additionally, the facility failed to adhere to current Centers for Disease Control and Prevention (CDC) guidelines by not utilizing Enhanced Barrier Precautions (EBP) during enteral tube medication administration to prevent the spread of multidrug-resistant organisms (MDROs) for 1 of 1 resident reviewed (Resident #2). The facility reported a census of 58 residents.

Inspectors wroteBased on observations, resident and staff interviews, and policy review the facility failed to ensure residents had the proper supplies for urinary independence for 1 of 1 residents reviewed (Resident #17). The facility reported a census of 57 residents.

Inspectors wroteBased on the Electronic Health Record (EHR) review, resident family interview, family interview, staff interview and policy review the facility failed to provide access to personal funds managed by the facility or manage personal funds deposited at the facility for 2 of 3 residents reviewed (Resident #11 and #30). The facility reported a census of 57 residents.

Inspectors wroteBased on Electronic Health Records (EHR) review, staff interview, family interview and policy review the facility failed to notify the resident's representative / family / Power of Attorney (POA) when a resident had a change in condition that lead to a transfer to the Emergency Department (ED) for 1 of 3 residents (Residents #10) reviewed. The facility reported a census of 57 residents.

Inspectors wroteThe facility failed to properly complete the Centers of Medicare & Medicaid form #10123 for 1 of 3 sampled residents. (Residents #4). The facility reported a census of 58 residents. Findings Include: The ABN form #10123 dated 12/23/25 for Resident #4 revealed the Social Worker documented a 48 hour notice waived. During an interview on 3/18/26 at 1:14 PM, the Social Worker reported that she had completed form #10123 and documented that Resident #4 waived a 48-hour notice. She further stated she could not recall the rationale for the waiver and indicated she would investigate the matter. During an interview on 3/18/26 at 2:51 PM, the Social Worker reported that she had been unable to locate documentation or rationale regarding the resident's waiver of the 48-hour notice on form #10123. [...]

Inspectors wroteBased on clinical record review, facility policy review and staff interview the facility failed to discontinue antipsychotic medication when ordered to be stopped therefore the medication was continued to be administered for 1 out of 5 residents (Resident #20 ) for unnecessary medication. The facility reported a census of 57 residents.

Inspectors wroteBased on clinical record review, facility record review, staff interviews and facility policy review the facility failed to report an allegation of abuse to the Iowa Department of Inspections & Appeals and Licensing (DIAL) within 2 hours of an allegation of abuse for 2 of 4 residents reviewed for abuse (Resident #3 and #50). The facility reported a census of 57 residents.

Inspectors wroteBased on clinical record review and staff interview the facility failed to complete a recapitulation of stay after discharge for 2 of 3 residents reviewed for discharges (Resident #61 and #63). The facility reported a census of 57 residents.

Inspectors wroteBased on Medication Administration Records - Treatment Administration Records (MAR-TAR) Electronic Health Records (EHR) review, document review, policy review and staff interviews the facility failed to incorporate the required recommendations from the Preadmission Screening and Resident Review (PASRR) level II determination and failed to refer a resident with a later identified with newly evident or possible serious MD or ID related condition to the appropriate state-designated authority for a level II evaluation for 3 out of 4 residents (Resident #4, #5, and #15) reviewed for PASRR requirements. The facility reported a census of 57 residents.

Inspectors wroteBased on Electronic Health Record (EHR) review, document review, staff interviews and policy review the facility failed to revise a comprehensive care plan to include updated recommendations when a Preadmission Screening and Resident Review (PASRR) Level II Outcome was completed for 1 of 3 residents reviewed (Resident #4). The facility reported a census of 57 residents.

Inspectors wroteBased on clinical record review, resident interview, staff interview and facility policy review the facility failed to provide bathing assistance twice weekly for 2 of 3 residents reviewed for bathing (Resident #20 and #50). The facility reported a census of 57 residents.

Inspectors wroteBased on Electronic Health Record (EHR) review, Medication Administration Record - Treatment Administration Record (MAR-TAR) review, policy review and staff interviews the facility failed to provide appropriate interventions for the urinary catheter to provide appropriate services to prevent urinary tract infections to 1 of 3 residents reviewed (Resident #10). The facility reported a census of 57 residents.

Inspectors wroteBased on Electronic Health Records (EHR), staff interview, observation and policy review the facility failed to implement policies and procedures regarding the technical aspect of feeding tubes by pushing enteral formula with a piston syringe into feeding tube for 1 of 1 residents (Resident #2). The facility reported a census of 57 residents.

Inspectors wroteBased on clinical record review and staff interview the facility failed to address dementia care for 2 out of 3 residents reviewed (Resident #7 and #28). The facility reported a census of 57 residents.

Inspectors wroteBased on record review, manufacturer's guidelines and staff interview, the facility failed to assure residents insulin pen was primed by performing a safety check prior to insulin administration preventing a significant medication error for 1 of 1 resident reviewed (Resident #16). The facility reported a census of 58 residents.

Inspectors wroteBased on record review and staff interviews the facility failed to provide and maintain accurate resident records to accurately record residents weights in the facility for 1 of 3 residents (Residents #35). The facility reported a census of 57 residents.

Inspectors wroteBased on previous CMS-2567 review, staff interview and facility policy review the facility failed to ensure a comprehensive, effective Quality Assessment and Performance Improvement (QAPI) program. The facility reported a census of 57 residents.

Inspectors wroteBased on record review, interview, and facility policy the facility failed to have a Infection Preventionist present for their quarterly Quality Assessment and Assurance (QAA) meetings. The facility reported a census of 57.

Inspectors wroteBased on record review and staff interviews the facility failed to update care plan interventions for resident after falls for 1 of 3 residents reviewed, (Resident #2).

Inspectors wroteBased on clinical record review, interviews, and facility policy, the facility failed to ensure bed hold notice was signed by residents and or the resident's responsible person when residents transferred out of the facility and failed to provide written notice of bed hold for 4 of 4 residents reviewed (Residents #4, #11, #40 and #45). The facility reported a census of 50 residents.

Inspectors wroteBased on clinical record review, resident interview, staff interview, observation, and policy review the facility failed to provide an opportunity for bath or shower to 4 of 6 residents reviewed (Residents #2, #37, #46, and #202). The facility reported a census of 50 residents.

Inspectors wroteBased on document review and staff interview the facility failed to employ a clinically qualified nutrition professional by not having a Certified Dietary Manager (CDM). The facility reported a census of 50 residents.

Inspectors wroteBased on clinical record review and staff interview, the facility failed to obtain physical signatures or record attempts to obtain physical signatures on notification of the Notice of Medicare Non-Coverage (NOMNC) Centers of Medicare & Medicaid (CMS)-10123 and CMS form CMS-10055 for 1 of 3 sampled residents (Residents #204). The facility reported a census of 50 residents. Findings Include: Record review for Resident #204 revealed form CMS 10123-NOMNC with a services end date of 9/4/24. Resident #204's representative gave verbal consent for signature on 9/4/24 however lacked a signature of resident or resident representative. Review of Resident #204's Progress Notes lacked any documentation on any attempts to obtain physical signatures on CMS 10123-NOMNC and CMS-10055. [...]

Inspectors wroteBased on resident interview, family interview, staff interview, and policy review the facility failed to ensure 1 of 1 resident's personal property was protected from loss or theft, (Resident #48). The facility reported a census of 50 residents.

Inspectors wroteBased on clinical record review and staff interview the facility failed to revise and update care plans to include and address high risk medications and side effects to watch for 1 out of 22 sampled residents reviewed for comprehensive care plans (Resident #13). The facility reported a census of 50 residents.

Inspectors wroteBased on record review, resident and staff interviews and facility policy review the facility failed to provide physician ordered daily weights 1 of 1 residents reviewed (Resident #11) and failed to provide pressure ulcer dressing changes as ordered by the physician for 1 of 1 residents reviewed (Resident #44). The facility reported a census of 50 residents.

Inspectors wroteBased on clinical document review, staff interview, and policy review the facility failed to provide adequate nursing supervision for 2 of 3 residents reviewed (Residents #22, and #48). The facility reported a census of 50.

Inspectors wroteBased on clinical record review and staff interview the facility failed to identify side effects, non-pharmalogical interventions to try prior to medication, specific targeted behaviors related to high risk medications in 2 out of 5 sampled residents reviewed (Resident #4 and #13). The facility reported a census of 50 residents.

Inspectors wroteBased on observation, staff interview, and infection control policy the facility failed to use universal infection control measures and Enhanced Barrier Precautions (EBP) during incontinence cares for 1 of 3 residents reviewed for infection control (Resident #45). The facility reported a census of 50 residents.

Inspectors wroteBased on observations and diet orders the facility failed to assure the food was prepared and appropriate to meet resident's needs according to their assessment, diet orders and care plan. Observations determined that 3 residents did not get the food in their ordered texture and 2 of the 3 residents have an order for an altered diet and are identified as moderately impaired cognition, (Resident #5, #6 and #7). This failure resulted in residents receiving Immediate Jeopardy to the health, safety, and security of the resident. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of July 25, 2024 on July 26, 2024 at 4:07 p.m. The Facility Staff removed the Immediate Jeopardy on July 26, 2024 through the following actions: a. Staff education was provided to the individual's passing meals on 7/25/24. b. [...]

Inspectors wroteBased on review of the planned menu, observation and staff interviews facility staff failed to follow the planned menu for residents. The facility identified a census of 46 residents.

Inspectors wroteBased on observations, facility record review and resident and staff interviews the facility failed to ensure proper temperatures for foods served to residents. The facility reported a census of 46 residents. Finding Include: Ongoing observation on 7/26/24 starting at 12:03 p.m., revealed the following: a. Observation of 3 dietary trays sitting on the table with covers on upon entering the kitchen. b. Observation during meal service Staff C, Dietary Manager called call room trays were ready. Verified with Staff C the room tray was ready to leave the kitchen and go to the resident. Asked Staff C to take meal temperatures. Temperatures are as follows: Fish Sticks- 94.3 degrees Fahrenheit (F), Carrots 93.5 degrees F and cheesy rice 102 degrees F. Staff C left the cover off of the meal tray. Approximately 10 minutes later Staff C revealed the room tray needed to be remade. c. [...]

Inspectors wroteBased on observations, resident and staff interviews, and facility policy reviews the facility failed to provide at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care. The facility identified a census of 46 residents.

Inspectors wroteBased on observations, record review, staff interviews and policy reviews, the facility failed to provide proper hand hygiene with perineal care for 1 of 3 residents reviewed (Resident #12). The facility also failed use proper hand hygiene during dining service for 2 out of 3 residents reviewed (Resident #17 & #18) and when preparing food in the kitchen. The facility reported a census of 46 residents.

Inspectors wroteBased on observations, staff interview and facility policy review the facility failed to provide for resident's dignity during dining. The facility reported a census of 46 residents.

Inspectors wroteBased on facility record review and resident and staff interviews, the facility staff failed to provide reasonable accommodation of needs by not placing the call light within reach of residents for 2 out of 6 residents reviewed (Resident #1 and #6). The facility reported a census of 46 residents. 1. The Grievance Resolution form dated 5/28/24 at 1:00 PM identified Resident #1 stated the call light was left out of reach after cares. The resident called the front desk to ask for assistance. The grievance conclusion identified staff confirmed the call light was out of reach upon entering the resident's room. Corrective action identified as education to staff on call lights. The Grievance Resolution form dated 6/10/24 identified Resident #1 reported during a mechanical lift transfer the nurse left the resident unattended and without a call light. [...]

Inspectors wroteBased on record review and interviews the facility failed to use the mechanical lift in an appropriate manner to avoid hazards and prevent accidents for 1 of 3 residents reviewed (Resident #1). The facility reported a census of 46 residents.

Inspectors wroteBased on observation, staff interview and facility policy, the facility failed to provide complete and appropriate incontinence care in a manner to prevent urinary tract infections for 1 of 3 residents observed (Resident #12). The facility reported a census of 46 residents.

Inspectors wroteBased on facility record review and resident and staff interviews, the facility staff failed to consistently answer call lights within a reasonable amount of time. Residents reported call light response time over 15 minutes for 3 out 6 residents reviewed (Residents #1, #8, and #15). The facility reported a census of 46 residents. 1. The Grievance Resolution form dated 5/28/24 at 1:00 PM identified Resident #1 turned on the call light at 6:30 AM. The call light wasn't answered until 7:30 AM. The resident reported incontinence due to the delay. The investigation listed on the grievance included staff educated on answering call lights in a timely manner. The Grievance identified corrective action included education to staff regarding call light response time. 2. [...]

Inspectors wroteBased on observations, resident and staff interviews and facility policy review the facility failed to provide alternatives or substitutions during meals to residents. The facility reported a census of 46 residents. Finding Include: 1. Review of the grievances provided by the facility revealed the following: a. Summary of the grievance- 4/1/24 There have been numerous residents with weight loss concerns since the change of dietary rules for residents' choice with meals. Options have been taken away from them. It's been told to the residents if its not on the menu, they can't have it This includes toast, yogurt, applesauce, pudding, eggs, ect. Steps taken to investigate- Executive Director educated staff there is a daily menu with alternative menu option as well. Summary of findings- Residents will choose between a daily menu or an alternative menu. [...]

Inspectors wroteBased on observations and diet orders the facility failed to assure the food was prepared and appropriate to meet resident's needs according to their assessment, diet orders and care plan. Observations determined that 5 residents, (Residents #11, #15, #26, #27 and #34) did not get the food in their ordered texture and 3 of the 5 residents that have an order for an altered diet are identified as moderately impaired cognition and 1 resident did have an episode of choking from being served the incorrect diet on 10/14/23. This failure resulted in Immediate Jeopardy to the health, safety, and security of the resident. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of October 14, 2023 on January 24, 2024 at 3:26 p.m The Facility Staff removed the Immediate Jeopardy on January 24, 2024 through the following actions: a. [...]

Inspectors wroteBased on observations, clinical record, facility policy, Centers for Disease Control and Prevention (CDC), and staff interviews, the facility failed to don and doff Personal Protection Equipment (PPE) correctly, dispose of PPE correctly, disinfect reusable PPE correctly, disinfect used laundry containers correctly, and perform hand hygiene in between assistance residents eat their meals. The facility reported a census of 42 residents.

Inspectors wroteBased on observations, facility policy, and staff interview the facility failed to provide for resident's dignity during dining when staff engaged in conversation that was not resident focused. The facility reported a census of 42 residents.

Inspectors wroteBased on observation, facility policy, and staff interview, the facility failed to place grievance forms in a location accessible to residents. The facility reported a census of 42 residents.

Inspectors wroteBased on personnel file reviews, staff interviews, and facility policy review, the facility failed to ensure all employees had an Iowa Criminal Background check and dependent adult/child abuse registry check completed prior to working in the facility for 1 out of 5 employees reviewed (Staff A). The facility reported a census of 42 residents.

Inspectors wroteBased on facility records, facility policy, and family, resident, and staff interviews, the facility failed to answer call lights within 15 minutes. The facility reported a census of 42 residents.

Inspectors wroteBased on document review and staff interview the facility failed to verify professional nursing licensure prior to hire for 1 of 3 staff members reviewed (Staff A). The facility reported a census of 28 residents.

Inspectors wroteBased on observations, resident and staff interviews, and facility policy review the facility failed to ensure the kitchen had the appropriate staff to carry out the tasks of the kitchen in a safe and effective manner. The facility identified a census of 42 residents.

Inspectors wroteBased on review of the planned menu, observation and staff interviews facility staff failed to follow the planned menu for residents. The facility identified a census of 42 residents.

Inspectors wroteBased on observations, facility record review and resident and staff interviews the facility failed to ensure proper temperatures for foods served to residents. The facility reported a census of 42 residents. Finding Include: Interview on 1/22/24 at 10:29 a.m., with Resident # 11 revealed the eggs were cold when she received them this morning. Resident #11 revealed staff did warm them up but it happens all the time. Interview on 1/22/24 at 10:07 a.m., with Resident # 2 revealed the food is always cold when she gets it. Resident #2 further revealed she does not like most of the food so will order an alternative but it takes forever to get the food. Lunch tray requested on 1/22/24 at 12:54 p.m., Dietary Manager (DM) revealed everyone had been served. DM served on a plate chicken breast, peas in a cup, breadstick, and brownie and covered. Temperature of food was checked as follows: [...]

Inspectors wroteBased on observations, resident and staff interviews, and facility policy reviews the facility failed to provide at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care. The facility identified a census of 42 residents.

Inspectors wroteBased on observations, staff interviews, and facility policy reviews the facility failed to ensure food was stored and prepared under sanitary conditions. The facility identified a census of 42 residents.

Inspectors wroteBased on facility policy and staff interview, the facility failed to make good faith attempts to correct quality deficiencies and have governance or leadership oversight with their Quality Assurance and Performance Improvement program (QAPI). The facility reported a census of 42 residents.

Inspectors wroteBased on facility documents, facility policy, and staff interview, the facility failed to have the required Quality Assurance and Performance Improvement (QAPI) members present for meetings. The facility reported a census of 42 residents.

Inspectors wroteBased on observations, staff interviews and policy review the facility failed to provide a clean homelike environment for all the residents living in the facility by not changing soiled linens or cleaning ceiling vent for 2 of 4 residents reviewed (Residents #2 and #193). The facility reported a census of 42.

Inspectors wroteBased on clinical record review and staff interview the facility failed to notify the Long Term Care (LTC) Ombudsman for 3 of 4 residents reviewed who transferred to the hospital (Resident #1, #13 and #20). The facility reported a census of 42 residents.

Inspectors wroteBased on clinical record review, interviews, and facility policy, the facility failed to ensure bed hold notice was signed by resident and or the resident's responsible person when residents transferred out of the facility for 3 of 4 residents reviewed (Residents #1, #13 and #34). The facility reported a census of 42 residents.

Inspectors wroteBased on clinical record, facility policy, and staff interview, the facility failed to accurately code a Minimum Data Set (MDS) for 1 of 14 residents reviewed (Resident #20). The facility reported a census of 42 residents.

Inspectors wroteBased on clinical record, facility policy, and staff interview, the facility failed to submit a Preadmission Screening and Resident Review (PASRR) for a change in condition for 1 of 2 residents reviewed (Resident #10). The facility reported a census of 42 residents.

Inspectors wroteBased on clinical record review and staff interview the facility failed to revise and update care plans to include and address high risk medications and side effects to watch for in 1 out of 13 sampled residents reviewed for comprehensive care plans (Resident #11). The facility reported a census of 42 residents.

Inspectors wroteBased on clinical record, facility policy, and staff interviews, the facility failed to follow physician orders for 1 of 15 residents reviewed (Resident #32). The facility reported a census of 42 residents.

Inspectors wroteBased on clinical record, facility policy, and staff interview, the facility failed to implement non pharmacological care plan interventions prior to obtaining an order for a psychotropic medication for 1 of 6 residents reviewed (Resident #41). The facility reported a census of 42 residents.

Inspectors wroteBased on clinical record, facility policy, and staff interview, the facility failed to obtain a correct verbal order for a psychotropic medication with a dose administered that was not what was ordered for 1 of 6 residents reviewed (Resident #41). The facility reported a census of 42 residents.

Inspectors wroteBased on clinical record, facility policy, and staff interviews, the facility failed to administer influenza vaccination to 2 of 5 residents reviewed (Residents #9 and #39). The facility reported a census of 42 residents.