Hillcrest Home

Inspectors wroteBased on observation, policy review, and staff interviews the facility failed to ensure all medications were dated when opened for six residents (Resident #23, #27, #31, #32, #44, and Resident #52). The facility reported a census of 51 residents. Observation on 7/1/26 at 4:08 p.m. revealed the medication cart contained the following medications stored and ready for use: Resident # 23, an open bottle of Latanoprost Ophth lacked an open date. Resident #27, an open bottle of Fluticasone Spray 50 microgram (mcg) lacked an open date. Resident #27, an open bottle of Dorzolamide Solution 2% lacked an open date. Resident #31, an open bottle of Lantanoprost Solution 0.005% lacked an open date. Resident #32, an open bottle of Polymyxin B/SolutionTrimethoprim lacked an open date. Resident #44, an open Atrovent Aerosol Inhaler lacked an open date. [...]

Inspectors wroteBased on staff interview, clinical record review, and policy review the facility failed to protect residents from misappropriation of property when resident medication became missing from the facility for 2 of 2 residents reviewed (Resident #40 and Resident #49). The facility reported a census of 51 residents.

Inspectors wroteBased on electronic health record (EHR) review, the Centers for Medicare and Medicaid Services (CMS) Long term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.20.1 October 2025, and staff interview the facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) assessment after a resident discharged off hospice services for 1 of 2 residents reviewed on hospice services (Resident #22). The facility reported a census of 51 residents.

Inspectors wroteBased on a review of the electronic health record (EHR) review, facility records, facility policy, and staff interviews, the facility failed to submit a PASRR update upon a new diagnosis of Post-Traumatic Stress Disorder (PTSD) for 1 of 1 resident reviewed (Resident #3). The facility reported a census of 51 residents. Findings Include:Resident #3's Minimum Data Set (MDS) assessment dated [DATE] documented an admission date of 4/23/25. The MDS documented Resident #3 wasn't currently considered by the state Level II PASRR process to have a serious mental illness, and/or intellectual disability or a related condition. The MDS included a Brief Interview for Mental Status (BIMS) score of 4 out of 15, indicating severe cognitive impairment. [...]

Inspectors wroteBased on record review, review of physician orders, staff interview, and facility policy review, the facility failed to include high risk medications on resident care plans for 2 of 4 residents reviewed (Resident #6 and Resident #23). The facility reported a census of 51 residents.

Inspectors wroteBased on clinical record reviews, staff interviews and policy review, the facility failed to ensure interventions were consistently implemented to prevent elopement for 1 of 1 resident reviewed (Resident #36). Resident #36, identified at risk for elopement, failed to have their wander alert device consistently checked to ensure proper function. The facility reported a census of 51 residents.

Inspectors wroteBased on electronic heath record review, policy review, and staff interviews the facility failed to account for a resident's experiences and potential triggers that might cause re-traumatization for 1 of 1 resident diagnosed with Post Traumatic Stress Disorder (PTSD) (Resident #3) . The facility reported a census of 51 residents.

Inspectors wroteBased on observation, electronic health record (EHR) review, facility document review, policy review, and resident and staff interviews, the facility failed to consistently respond to activated call lights within a timely manner for 1 of 17 residents reviewed (Residents #47). The facility reported a census of 51 residents. Findings Include:Resident #47's Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. The MDS listed Resident #47 required partial/moderate assistance for toileting hygiene and for toilet transfers. The MDS included diagnoses of urinary tract infection, osteoporosis, hyperlipidemia, and renal insufficiency. The Care Plan Focus initiated 5/29/26 identified Resident #47 had impaired mobility. [...]

Inspectors wroteBased on electronic health record (EHR) review, Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 user's manual review, and staff interviews revealed the facility failed to submit 2 completed Minimum Data Set (MDS) assessments for 1 of 5 residents reviewed. The facility reported a census of 43 residents.

Inspectors wroteBased on record review, staff and medical provider interviews, and policy review the facility failed to implement root cause analysis interventions for previous falls resulting in a fall with fracture, and to thoroughly assess a resident for possible injury after a fall for 1 of 3 residents reviewed for falls (Resident #1). The facility reported a census of 44 residents.

Inspectors wroteBased on record review, staff and family interviews, and policy review the facility failed to make prompt efforts to resolve and investigate a complaint/grievance and actively work toward resolution for 1 of 1 complaint letters reviewed (Resident #2). The facility reported a census of 44 residents.

Inspectors wroteBased on record review, staff and family interviews, and policy review the facility failed to promptly implement a new order for 1 of 3 residents reviewed for pain (Resident #2). The order given was to increase the dosage of as needed (PRN) Morphine (narcotic liquid pain medication) for an actively dying resident. The facility reported a census of 44 residents.

Inspectors wroteBased on record review, staff, family, and provider interviews, and policy review the facility failed to obtain an order to increase an as need (PRN) morphine (liquid pain medication) order for 1 of 3 residents reviewed who was actively dying (Resident #2). The facility also failed to obtain orders prior to suctioning a resident during end of life cares for 1 of 1 residents (Resident #2). The facility reported a census of 44 residents.

Inspectors wroteBased on observation, clinical record review, staff interview, and policy review, the facility failed to provide services that met professional standards regarding following physician orders with insulin administration for 1 of 5 residents reviewed for medication administration (Resident #16). The facility reported a census of 45 residents.

Inspectors wroteBased on personnel record review, staff interview, and policy review, the facility failed to ensure mandatory Dependent Adult Abuse training had been completed within 6 months of employment for 1 of 5 staff reviewed (Staff A). The facility reported a census of 45 residents.

Inspectors wroteBased on facility record review, staff interview, and policy review the facility failed to have the minimum required members present at their quarterly Quality Assurance (QA) meetings as directed by Centers for Medicare and Medicaid Services (CMS). The facility reported a census of 45 residents.

Inspectors wroteBased on clinical record review, policy and procedure review, and staff interviews the facility failed to treat a resident with respect and dignity in a manner that promotes maintenance or enhancement of his or her quality of life for 1 out of 5 resident reviewed. (Resident #1). The facility identified a census of 47 residents.

Inspectors wroteBased on record review, facility policy and procedure, and staff interviews, the facility failed to follow physicians orders for 2 of 4 residents reviewed for medication administration. (Resident #3 and Resident #4). The facility reported a census of 47 residents.

Inspectors wroteBased on observation, record review, and staff interviews the facility failed to follow a physician order resulting in an emergency room visit for 1 out of 3 residents reviewed for medication administration (Resident #2). The facility reported a census of 47 residents.