Hillcrest Care Center Inc

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Aug 8, 2024

  Based on observation, interview and record review, the facility failed to provide adequate supervision to ensure the safety of one resident (Resident #1). On 08/01/24 at 3:00 A.M., the facility failed to initiate a search for Resident #1 and implement the facility policy for missing residents when staff noticed the resident's call light on, but the room was empty. On 08/01/24 at 6:45 A.M., during morning medication pass, staff noted Resident #1 was not in his/her room. The staff finished the medication pass and reported to the charge nurse. On 08/01/24 at 8:00 A.M., the staff began searching for the resident and found the resident outside lying on the ground in the courtyard. The resident fell down outside in the late evening on 07/31/24, and lay on the ground until 08/01/24 at 8:15 A.M. […]

• Immediate jeopardy, isolatedF600Oct 12, 2022

  Based on observation, interview and record review the facility failed to protect one cognitively impaired resident (Resident #1) from sexual abuse when staff found Housekeeping Staff (HKS) A, nude from the waist down, on the bed leaning over Resident #1. The facility census was 68. The Administration was notified on 10/12/2022 of a Past Non-Compliance Immediate Jeopardy (IJ) which began on 10/8/2022. On 10/8/2022, the Director of Nurses (DON) was notified HKS A sexually abused Resident #1. Staff immediately assessed the resident and notified the police and ambulance. They removed HKS A from the Facility, and started an investigation. Facility staff was in-serviced on abuse and neglect policies and protocols. The IJ was corrected on 10/8/2022. […]

• No harm, potential for more than minimal, widespreadF814Jan 22, 2026

  Based on observation and interview, the facility failed to ensure the dumpster was maintained to keep pest out and/or to keep garbage contained in the dumpster. This deficient practice had the potential to affect all residents in the facility. The facility was 81. The facility did not provide a policy for maintaining the dumpster. Observations on 01/19/26 at 10:05 A.M., and 1:00 P.M., of the outside trash dumpster showed;- Each dumpster lid was open with visible garbage bags, boxes, and other miscellaneous debris inside. […]

• No harm, potential for more than minimal, patternF602Mar 28, 2025

  Based on interview and record review, the facility failed to ensure 26 residents out of 27 sampled residents (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24, #25 and #26) were free of misappropriation of their property when Bookkeeper A utilized resident trust accounts and resident cash for his/her own personal use totaling $20,110. The facility census was 84. The administration was notified on 03/28/25 of the Past Non-Compliance which occurred between 02/06/25 through 02/10/25. On 02/06/25, upon notification, the facility administrator started an investigation, notified the police department and the Department of Health and Senior Services of the misappropriation. […]

• No harm, potential for more than minimal, patternF677Aug 25, 2023

  Based on observation, interview, and record review, the facility failed to provide resident care for activities of daily living (ADLs) when the residents did not receive a minimum of two showers per week for six residents (Resident #7, #26, #33, #48, #57, and #65) out of 18 sampled residents. The facility's census was 75. The facility did not provide a policy related to shower frequency. 1. Review of Resident #7's medical record showed: - An admitted [DATE]; - Diagnoses of hypertension (high blood pressure), multiple rib fractures on the right side, lumbar spinal stenosis (narrowing of the spinal cord), essential tremor (disorder that causes rhythmic shaking), low back pain, dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday activities) and… […]