Hillcrest Nursing and Rehabilitation Community

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow professional standards of nursing practice for 5 of 12 residents (Resident #17, #1, #14, #23, and #29) reviewed for medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain best practices in the food service area resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 12/02/2025 at 10:05 AM, observed debris collected in the bottom of the ice scoop holder installed on the wall by the ice machine. According to the 2022 FDA Food Code section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils. (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch. (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) NonFOOD-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. [...]

Inspectors wroteBased on observation interview and record review, the facility failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). This deficient practice has the increased potential to result in waterborne pathogens to exist and spread in the facility's plumbing system and an increased risk of respiratory infection among all residents in the facility. Findings Include:On 12/02/2025 at 12:50PM, during an interview with Maintenance Supervisor (MS) B, regarding the water management plan, it was disclosed that room [ROOM NUMBER] has a non-operational shower (water lines) that is not being flushed. The water lines for the shower have been non-operational for over a year. At time of observation on 12/02/2025, the shower did not have a faucet handle and did not appear to be able to be turned on at the shower wall. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure medications were administered in accordance with physician orders without errors for 1 of 3 residents (Resident #17) observed during the medication administration task. This resulted in a facility medication error rate of 8.33% (3 errors out of 36 opportunities).

Inspectors wroteThis citation refers to intake MI00151516. Based on observation, interview and record review, the facility failed to implement the hot liquid policy for 1 resident (R1) of 4 residents reviewed, resulting in second degree burn caused by a hot liquid spill.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement care planned interventions for the prevention of skin breakdown in 2 residents (Resident #20 and #16) out of 10 residents reviewed for comprehensive care plans.

Inspectors wroteBased on interview and record review, the facility failed to follow professional standards of nursing practice for comprehensive assessments and medication administration for 2 residents (Resident #25 and #30), out of 10 residents reviewed for the provision of nursing services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to secure 1 of 2 medication carts (North Hall Medication Cart), resulting in the potential for misappropriation of resident medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement transmission-based precautions and utilize appropriate personal protective equipment for 1 resident (Resident #25) of 10 residents reviewed for transmission-based precautions, resulting in the potential for cross-contamination, disease exposure, and the development and spread of infection to a vulnerable population.

Inspectors wroteBased on observations, interviews and record review, the failed to provide adequate supervision to prevent falls for 3 Residents (R1, R2, and R3) of 3 residents reviewed for falls, resulting in R1 falling and sustaining a hip fracture and the potential for R2 and R3 to sustain serious injuries.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop and implement a meaningful activities program for 4 Residents (R1, R2, R3 and R4) of 4 residents sampled, resulting in residents sitting unsupervised and experiencing boredom without the option for diversional activities to decrease the risk of injury.

Inspectors wroteBased on observation, interview, and record review the facility failed to: 1. Date mark and discard potentially hazardous foods; 2. Properly cool potentially hazardous foods; 3. Ensure proper concentration of quaternary ammonium sanitizer; 4. Clean food and non-food contact surfaces to sight and tough; and 5. Ensure proper working order of the dish machine. These conditions resulted in an increased risk of contaminated foods and an increased risk of food borne illness that affected 55 residents who consume food from the kitchen. Findings Include: 1. During the initial tour of the kitchen, starting at 9:20 AM on 10/1/23, an interview with [NAME] I found that most foods are date marked for a seven-day discard, but foods made in house would usually be kept for three days. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure 1 Resident, (R12) had a legal representative to assist her in making medical decisions, resulting in R12 not having anyone to act in her best interest in making medical decisions.

Inspectors wroteBased on observations, interview, and record review, the facility failed to provide ADL care per the current plan of care, and/or implement a plan of care for dining, for 2 Residents (R12 and R15), resulting in them not receiving routine showers and assistance required with eating.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision, implementation of meaningful intervention to prevent falls and ensure the fall care plan was followed for 1 Resident (R1), resulting in R1 sustaining multiple falls and the potential for serious injury.

Inspectors wroteBased on observations, interviews, and record review the facility failed to adequately assess and monitor 3 Residents (R12, R15 and R18) nutritional status and needs, resulting in R15 and R18 resident experiencing weight loss and the potential for R12 to have weight loss.

Inspectors wroteBased on interview and record review, the facility failed to ensure all pharmacy recommendations were received and acted on for 2 residents (R11 and R26) reviewed for medication reviews. This deficient practice resulted in R11 and R26 having pharmacy recommendations that were not communicated to the facility and not acknowledged by the physician for suggested changes to be made.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide collaborative hospice care for 2 Residents (R12 and R15), resulting in the potential for services and needs to be unmet.