Hillcrest Healthcare Center

Inspectors wroteBased on resident interviews, record review, and staff interview, the facility failed to include residents in their care plan meetings and ensure care plans were reviewed at least quarterly. Furthermore, the facility failed to revise the care plan for Resident #71's dentures. This was true for three (3) of five (5) residents sampled for care planning during the Long-Term Care Survey process. Census: 89 Resident identifier: #88, #71, #9a) Resident #71 During an interview on 06/22/26 at 12:16 PM, Resident #71 stated she had not been invited to attend care plan meetings. Review of Resident #71's medical records showed a care plan meeting had been held on 03/13/25 and the resident had attended. However, no further care plan meetings were documented since then. [...]

Inspectors wroteBased upon record review and staff interview, the facility failed to obtain consent from the resident's representative on the POST form, instead it was signed by a resident who did not have capacity at the time of consent. This was found to be true for one (1) of three (3) residents reviewed for Advanced Directives during the long term care survey process. Resident identifier: #11. Facility census: 89.

Inspectors wroteBased on record review and staff interview, the facility failed to provide documentation that the Notice of Medicare Non-Coverage (NOMNC) was delivered to resident representative. This was true for one (1) of two (2) residents sampled for Beneficiary notification during the Long-Term Care Survey process. Census: 89 Resident identifier: #101a) Resident #101 The Medicare Claims Processing Manual section 260.3.8 titled NOMNC Delivery to Representatives reads as follows: The NOMNC must be annotated with the following information on the day that the provider makes telephone contact: Reflect that all of the information indicated above was communicated to the representative; Note the name of the staff person initiating the contact, the name of the representative contacted by phone, the date and time of the telephone contact, and the telephone number called. [...]

Inspectors wroteBased upon record review and staff interview, the Pre-admission Screening Resident Record (PASRR) was not updated when the resident had new mental health diagnoses of Post Traumatic Stress Disorder (PTSD) and Major Depressive Disorder, and the PASARR was not coordinated with the Minimum Data Set (MDS). Failure to coordinate the PASARR and the MDS can lead to duplication of effort and testing. This was found to be true for one (1) of two (2) residents reviiewed during the long term care survey process. Resident identifier: #89. Facility census: 89.

Inspectors wroteBased on resident interview, record review, and staff interviews, the facility failed to ensure a dependent resident received services to maintain gained level of independence with activities of daily living (ADLs) after finishing therapy services. This was true for one (1) of four (4) resident sampled for ADLs during the Long-Term Care Survey process. Census: 89 Resident identifier: #9a) Resident #9 During an interview with Resident #9 on 06/22/26 at 11:49 AM, she stated she was supposed to walk daily with nursing staff since being discharged from therapy but has only walked once. A record review of the walking tasks for April, May, and June 2026 revealed Resident #9 walked with nursing staff once in the last three (3) months. The Physical Therapy discharge note dated 04/24/26 reads, discharge recommendations: transfers to wheelchair daily with assist of nursing staff. [...]

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to store and label medications within accepted standards of practice. A Humalog Insulin Kwikpen located in the medication cart was past its expiration date based on when the medication was opened. Additionally, a multi-use vial of tuberculin purified protein derivative (PPD) located in the medication refrigerator had not been dated when first accessed. These were random opportunities for discovery during the facility task of medication storage. Resident Identifier: #9. Facility Census: 89.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure Cardio-Pulmonary Resuscitation (CPR) interventions were initiated and continued until the arrival of emergency medical personnel for a resident observed with absence of vital signs with a Full Code status, resulting in death for one (1) of two (2) residents reviewed for death in the facility. This had the potential to affect all residents in the facility with a Full Code status. This immediate jeopardy began on [DATE] at approximately 3:00 AM when Resident #194 was observed with absence of vital signs. LPN #125 and Nurse Aide #126 reportedly initiated CPR but discontinued it prior to the arrival of EMS. The facility Administrator was informed of the Immediate Jeopardy (IJ) tag on [DATE] at 2:55 PM. [...]

Inspectors wroteBased on record review and staff interview the facility failed to provide adequate supervision to prevent avoidable accidents. This failed practice caused harm to Resident #245. Resident #245 fell from the shower bed and received hematoma and laceration to the head requiring sutures. The incident was corrected and will be sighted at past non-compliance. This failed practice was found true for (1) one of (6) six residents reviewed for accidents during the Long-Term Care Survey Process. Resident identifier: #245. Facility census: 90. Findings Include: a) Resident #245 A review of the facility reportable log on 04/15/25 at 11:30 AM, found a reportable for Resident #245 dated 09/29/24 at 9:45 AM, that summarized the incident as follows: Nursing Assistant (NA) #69 had Resident #245 in the shower room giving her a shower. [...]

Inspectors wroteBased on observation and staff interview the facility failed to provide food that was palatable by serving scorched beans. This was a random opportunity of discovery had had the potential to affect a limited number of residents residing in the facility. Facility census:

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Resident identifiers: #29, #19, #17, #28, and #43. Facility census: 90.

Inspectors wroteBased on record review and staff interview, the facility failed to provide the required Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) form to (2) one of three (3) residents reviewed for the facility's beneficiary protection notification practice and failed to issue the required Notification of Medicare Non-Coverage (NOMNC) in a timely fashion for two (2) of three (3) residents reviewed for beneficiary protection notification during an annual survey. Resident identifiers: #48 and #346. Facility census:

Inspectors wroteBased on medical record review and staff interview, the facility failed to provide evidence that a resident/resident's representative was provided with a written Notice of Transfer/Discharge for an acute hospital transfer. This was true for one (1) of three (3) residents reviewed for hospitalizations during the long-term care survey process. Resident identifier: #8. Facility census: 90.

Inspectors wroteBased on medical record review and staff interview, the facility failed to provide evidence that a resident/resident's representative was provided with a written Bed Hold Notice for an acute hospital transfer. This was true for one (1) of three (3) residents reviewed for hospitalizations during the long-term care survey process. Resident identifier: #8. Facility census: 90.

Inspectors wroteBased on record review and staff interview the facility failed to address recommendations made by the wound care service. This failed practice was found true for (1) one of (3) three residents reviewed for pressure ulcers during the Long-Term Care Survey Process. Resident identifier #17. Facility Census 90. Findings Include: a) Resident #17 During the initial interview on 04/14/25 at 11:51 AM, Resident #17 stated, I have a couple places on my butt. I feel like they are getting better. I am not sure how they got there. A record review on 04/15/25 at 11:35 AM, revealed a progress note dated 03/11/25 from the wound care service recommending adding modular protein and multivitamin with zinc supplements. Further record review of Resident #17's orders revealed that the modular protein and the multivitamin with zinc supplements had not been added. [...]

Inspectors wroteBased on observation, staff interview and record review, the facility failed to provide dental services by failing to schedule oral surgery in a timely manner as recommended by the dentist. This is true for Resident #7. Facility Census 90. Findings Included: a) Resident #7 On 04/14/25 at 3:18 PM Resident #7 was observed to have broken and missing teeth. On 04/15/25 at 09:08 AM a review of resident's medical records revealed the following: Resident #7's care plan stated that the resident had a potential for oral/dental health problems affecting ADLs r/t Poor oral hygiene, has own teeth, missing, requires assist of staff with oral care. The intervention included dental consult as needed. A review of resident's last Dental exam summary on 01/04/22 stated Recommending all remaining teeth to be extracted and attached a referral to see an oral surgeon. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a resident received a response to a formal grievance. This was a random opportunity for discovery. Resident identifier: #76. Facility census: 88.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure medications were stored and labeled in accordance with currently accepted professional principles. These were random opportunities for discovery. Resident Identifiers: #17, #59, #7, #77, #74, and #5. Facility Census: 85. Findings Included: a) [NAME] Wing Medication Cart On 04/25/23 at 8:34 AM, Licensed Practical Nurse (LPN) #95 was observed during medication administration. At this time, the medication cart on the west wing was audited. The medication cart audit found two (2) insulin kwik pens not dated upon the initial administration. The first insulin kwik pen (Lantus) not dated was for Resident #17 and the second insulin kwik pen (Novolog) was for Resident #59. On 04/25/23 at 8:38 AM, LPN #95 confirmed neither insulin kwik pen was dated upon the initial administration. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure complete and accurate medical records. Two (2) of three (3) residents reviewed for the care area of pain had incomplete pain assessments performed. Two (2) of 22 residents reviewed in the long-term care survey sample had incomplete Physician's Orders for Scope of Treatment (POST) forms. Additionally, one (1) of 22 residents reviewed in the long-term care survey sample had conflicting information regarding end-of-life wishes. Resident identifiers: #62, #21, #283, #1. Facility census: 85.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure complete and accurate Minimum Data Set (MDS) assessments for two (2) of 22 residents reviewed during the long-term care survey process. Resident identifiers: #44, and #81. Facility census: 85.

Inspectors wroteBased on observation and staff interview, the facility failed to maintain appropriate professional standards for the care of urinary catheters to prevent infections. This was a random opportunity for discovery. Resident Identifiers: #26. Facility Census: 85. Findings Included: a) Resident #26 On 04/24/23 at 10:53 AM, Resident #26's urinary catheter bag was observed laying in the floor by the bed. On 04/24/23 at 10:56 AM, Registered Nurse (RN) #72 confirmed the catheter bag was laying in the floor by the bed. RN #72 stated, I'll fix this. On 04/24/23 at 2:00 PM, the Director of Nursing (DON) was notified and confirmed the catheter bag should not be laying in the floor. No further information was obtained during the long-term survey process. .

Inspectors wroteBased on observation and staff interview the facility failed to ensure respiratory care was provided according to professional standards of practice. During a random opportunity for discovery, it was noted Resident #41's oxygen concentrator was set on the incorrect flow rate. Resident identifier: #41. Facility census: 85.

Inspectors wroteBased on record review and staff interview, the facility failed to complete hemodialysis communication records between the facility and the dialysis center. This is true for one (1) of one (1) residents reviewed under the care area of dialysis during the long term care survey process. Resident Identifier: #69. Facility Census: 85. Findings Included: a) Resident #69 On 04/25/23 at 1:45 PM, the hemodialysis communication book was reviewed for Resident #26. The review found the following hemodialysis communication sheets were incomplete: [...]

Inspectors wroteBased on record review and staff interview the facility failed to respond to pharmacy recommendations. This was true for one (1) of five (5) residents reviewed for unnecessary medications during the Long Term Care Survey Process. Resident identifier: #70. Facility census: 85.

Inspectors wroteBased on observation and staff interview, the facility failed to maintain the kitchen in a safe and sanitary manner in accordance with professional standards of practice. During the kitchen tour it was discovered dirty floors in the walk-in cooler and freezer, the refrigerator had rusted shelves, a rubber strip for the refrigerator needed to be repaired and there was no temperature log for a resident's personal refrigerator. This practice had the potential to affect an isolated number of residents. Facility census: 85.