Hillcrest Nursing Home

Inspectors wroteResidents did not have a dignified experience when residents were sitting at a table and one resident was served lunch and the others had to wait 15 minutes for their lunch on September 29, 2025 Based on observation, interview, and record review, the facility failed to ensure residents who were sitting on the same table were served at the same time for three of five residents reviewed for dining observation (Residents 23, 29, and 36) when Residents 23, 29, and 36 receive their food 10 minutes after Residents 5 and 47 were served their lunch. This failure had the potential for Residents 29, 23, and 36 to feel less dignified and respected because they had to sit and watch other residents eat their lunch.

Inspectors wroteThe facility did not implement antibiotic stewardship program according to facility policy. Based on interview and record review, the facility failed to implement its policy and procedure on antibiotic stewardship (a set of practices aimed at ensuring the safe and effective use of antibiotics [medications used to treat infections]) for two of six residents reviewed for antibiotic use (Residents 1 and 17) when Residents 1 and 17's Loeb's [a set of clinical guidelines for healthcare providers in long-term care facilities to help them decide when to start antibiotics for residents] Minimum Criteria for Initiating Antibiotic Therapy form were not filled out completely. [...]

Inspectors wroteThree rooms have less than 80 square feet per resident in rooms [ROOM NUMBER]. Based on observation, interview, and record review, the facility failed to provide a minimum of 80 square feet (sq. ft.) of livable space per resident for three of 32 resident rooms (rooms [ROOM NUMBER]). This failure had the potential for the residents housed in rooms [ROOM NUMBER] to not have the ability to move about freely if the square footage limited their personal space.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food safety when: 1. Cut watermelon and butter were stored in refrigerator at a temperature of 60 degrees Fahrenheit (unit of measurement). 2. Two cracked and chipped spatulas were observed in the kitchen's utensils drawer. 3. The microwave's anti-splatter shield had a layer of food residue. These failures had the potential to cause foodborne illnesses to 51 residents who receive food served by the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure menus were followed for 21 residents on a regular and Controlled Carbohydrate diet (CCHO- eating the same amount of carbohydrates every day, to help keep blood sugar, or glucose levels stable) during lunch on July 22, 2024. This failure had the potential for 21 residents on a regular and CCHO diet to have altered nutritional intake and weight loss.

Inspectors wroteBased on interview and record review, the facility failed to ensure the code status (emergent treatment options during a life-threatening event) and Advance Directives (written instruction, such as a living will or durable power of attorney for health care, recognized under State law, relating to the provision of health care when the individual is incapacitated), were consistent and accurately documented for two of 12 residents reviewed for Advanced Directives (Residents 15 and 47). These failures had the potential to result in a delay of treatment for Residents 15 and 47 as related to advance directives, or for life sustaining measures to be rendered against what the resident wanted.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Minimum Data Set (MDS- a computerized assessment instrument) Assessments were accurately completed to reflect the resident's status, care, and services in the physical restraint (any device or method used to limit a resident's movement) under Section P for one of six residents reviewed for MDS (Resident 43). This failure had the potential to cause inaccuracy in identifying Resident 43's care and support needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices when a Certified Nursing Assistance (CNA 4) did not follow facility policy and procedure in handling soiled linen. This failure had the potential to cause and spread infectious disease (disease caused by bacteria, viruses, fungi, or parasites) to 51 residents and staff in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure three out of thirty-one rooms (Rooms 29, 31 and 32) had the required 80 square feet of space for each resident when: 1. For room [ROOM NUMBER], the room measured 152.83 sq ft (square feet) = 76.41 sq.ft. each. 2. For room [ROOM NUMBER], the room measured 140 sq ft. =70 sq. ft each. 3. For room [ROOM NUMBER], the room measured 141.67 sq ft= 70.83 sq ft each. This failure has the potential to limit the freedom of movement for the residents that occupied the rooms, which could place them at risk for injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage areas were maintained, as well as safe and sanitary practices were maintained in the kitchen when: 1. The ice machine was not kept in a clean and sanitary condition, which put 54 Residents, who used or ingested ice from this machine, at risk for foodborne illness (illness acquired from ingesting contaminated food). 2. There were food crumbs and miscellaneous items in an enclosed area on a countertop that had the potential to promote bacteria growth within this area as well as attract microorganism (small organisms which have the potential to cause disease) carrying pests. 3. The floor under the deep fryer had food crumbs and trash that had the potential to attract microorganism carrying pests. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Notice of Transfer/Discharge forms were complete for three of three sampled residents (Residents 41, 43 and 55). This failure led to incomplete discharge records for Residents 41, 43, and 55, who were discharged to a psychiatric hospital to be evaluated for depression, however, the Notice of Transfer/Discharge was not completed per the facility's policy and procedure.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the menus were followed when: 1. Thirty three out of fifty-four residents were on a regular, No Added Salt (NAS), and low-fat/ low cholesterol diet and received the incorrect dessert for lunch on February 28, 2022. 2. Nine out of fifty- four residents on a large portion diet received four ounces of milk instead of eight ounces of milk for lunch on February 28, 2022. These failures had the potential to decrease the nutritional intake and meal satisfaction for the 54 residents who are immuno-compromised.

Inspectors wroteBased on staff interviews and record reviews, the facility failed to ensure an annual (a comprehensive assessment for a resident that must be completed on an annual basis) Minimum Data Set (MDS- a computerized assessment tool) assessment for one of five residents (Resident 6) selected to be reviewed for resident assessments. This failure had the potential to cause a delay in identifying care and support needs for Resident 6.

Inspectors wroteBased on record reviews and staff interviews, the facility failed to ensure a quarterly (a quarterly review for resident that must be completed every 3 months) Minimum Data Set (MDS- a computerized assessment tool) assessment for two of five residents (Resident 3 and Resident 4) selected to be reviewed for resident assessments. This failure had the potential to cause a delay in identifying care and support needs for Resident 3 and Resident 4.

Inspectors wroteBased on record review and interview, the facility failed to ensure Minimum Data Set (MDS- a computerized assessment instrument) Assessments were completed to accurately reflect the resident's status, care and services, in the area of active diagnosis for one of two sampled residents (Resident 505) reviewed. This failure had the potential to cause inaccuracy in identifying resident 505's care and support needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Bowel and Bladder care plan was developed to meet and address the needs and goals for one out of five sampled residents (Resident 5). This failure has the potential to prevent Resident 5 from reaching his maximum functional capability and/or prevent any complications that may arise from bowel and bladder incontinence (the lack of voluntary control to hold bowel [stool] and bladder [urine].)

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff demonstrate the ability to carry out an activity that is within the scope of practice a staff is certified to perform when Certified Nurse Assistant 3 (CNA 3) gave Resident 5 a lunch tray that belonged to another resident. This failure to demonstrate competency had the potential for a diminished quality of service and care for one of five sampled residents (Resident 5).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection prevention and control measures when: 1. A Certified Nurse Assistant (CNA 1) did not remove gloves and observe hand hygiene after handling soiled linens, and before placing clean new ones on resident's bed. This failure had the potential to spread contaminants present from the soiled linens onto the clean new ones, that could potentially harm one unsampled resident (Resident 19). 2. A Housekeeping Aide 1 (HA 1) placed an undisinfected container of sanitizing wipes on top of one dining table that was disinfected in preparation for the lunch meal. This had the potential to spread pathogens to residents who use the dining table for eating meals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safety practices related to residents smoking for two of two residents (Resident 33 and 38), when Residents 33 and 38 were observed smoking without supervision. This failure has the potential to place Resident 33 and 38 at risk for burns.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that for three out of 31 rooms (Rooms 29, 31 and 32) each resident had the required 80 square feet of space when: 1. For room [ROOM NUMBER], the room measured 152.83 sq ft (square feet) = 76.41 sq ft each. There were two residents (Resident 21 who used a wheelchair) and (Resident 48 who ambulated without assistive device). 2. For room [ROOM NUMBER], the room measured 140 sq ft =70 sq ft each. There were two residents (Resident 34 who used a walker to ambulate- [walk]) and ( Resident 32 who ambulated without assistive device). 3. For room [ROOM NUMBER], the room measured 141.67 sq ft= 70.83 sq ft each. There was one resident (Resident 32 who ambulated without assistive device) in a room with two beds. [...]