Hillcrest Care Center

In the surveyor’s words

From the most serious findings on record at Hillcrest Care Center, in the surveyor’s own words.

• Actual harm, isolatedF689Mar 30, 2023

  Based on record review and interviews, the facility failed to keep residents safe from accident hazards related to fall prevention for two (#16 and #32) of two residents reviewed for falls, out of 29 sample residents. Resident #16 had a history of fall and was assessed to be at high risk for repeated falls. Facility assessment and medical diagnosis revealed the resident had muscle weakness, poor balance, unsteady gait. Additionally, the resident had severe cognitive impairment that affected the resident judgment and ability to make sound safe decisions. Per the resident's medical records, the resident forgot or was unable to use the call light when she needed assistance to make safe transfer from surface to surface. […]

• Actual harm, isolatedF689Dec 16, 2021

  Based on interview and record review, the facility failed to prevent a fall with injuries during facility transportation of one (#28) of three out of 23 sample residents. The facility failed to ensure Resident #28 was provided safe transportation. Due to the facility ' s failures Resident #28 was loaded into the van and was not secured properly before being left unattended while the transportation driver left the residents side to open the door on the other side of the vehicle. Because of this failure the resident's wheelchair was unstable and rolled forward out of an open door and out of the van causing the resident to fall approximately three feet down out of the van, face-forward onto the asphalt. […]

• No harm, potential for more than minimal, widespreadF880Mar 30, 2023

  Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to: -Ensure professional standards of infection control were followed while cleaning resident rooms; -Ensure that different cleaning cloths were used to clean and disinfect different potentially contaminated surfaces; -Ensure housekeeping staff changed gloves and performed hand hygiene consistently when moving from a task where the staffs hand became contaminated form cleaning and or touching a contaminated surface within a resident's room before cleaning the next surface; -Ensure housekeeping staff… […]

• No harm, potential for more than minimal, patternF880Oct 3, 2024

  Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically the facility failed to ensure residents were offered hand hygiene before meals in both the dining room and during the delivery of room trays. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention's (CDC) Hand Hygiene in Healthcare settings, revised 2/27/24, retrieved from https://www.cdc.gov/handhygiene/index.html on 10/8/24, Patients and visitors should clean their hands before preparing or eating food. […]

• No harm, potential for more than minimal, patternF565Jul 16, 2024

  Based on observations, record review and interviews, the facility failed to address and/or act promptly upon the grievances and recommendations during resident council on issues of resident care and quality of life in the facility that were important to the residents. Specifically, the facility failed to ensure resident council grievances were addressed to resolve resident concerns related to residents being left in the dining room for up to an hour after meals, lack of staff in the dining room, inappropriate staff conversations, rude staff members and call light response times. Findings include: I. Facility policy The Resident and Family Grievance policy, dated 4/23/23, was received from the nursing home administrator (NHA) on 7/16/24 at 2:00 p.m. […]