Hillcrest Center

In the surveyor’s words

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

• Actual harm, isolatedF684Apr 16, 2026

  Based on review of clinical records, hospital records, and staff interviews, it was determined the facility failed to appropriately monitor and notify the physician of repeated critically elevated blood pressure readings and failed to ensure an anti-hypertensive medication was administered as ordered by the physician. This failure resulted in actual harm to Resident R12 who sustained uncontrolled hypertension, transferred to the hospital with a diagnosis of hypertensive urgency requiring hospital admission for one of 30 residents reviewed. (Resident R12)Findings include:Review of Resident R12's quarterly Minimum Data Set (MDS- federal mandated assessment tool) dated December 13, 2025, revealed the resident was admitted to the facility on [DATE]. […]

• Actual harm, isolatedF805May 2, 2025

  Based on review of clinical records, facility policy, dietary guidelines, and interview with staff, it was determined the facility failed to ensure Resident R369 was provided food items congruent with his/her dysphagia diet. This failure resulted in actual harm to Resident R369 who was able to obtain food items incongruent with his/her dietary restrictions, experienced a choking episode, requiring Cardio Pulmonary Resuscitation (CPR), and transfer to the hospital for one of 33 reviewed (Resident R369). Findings include: Review of the facility provided guidelines, Diet and Nutritional Care Manual Dysphagia Advanced (Level 3) or Mechanical (Dental) Soft Diet revealed This diet is used for individuals with mild oral and/or pharyngeal phase dysphagia. […]

• Actual harm, isolatedF686Nov 14, 2022

  Based clinical record review, review of facility policy and staff interview, it was determined that the facility failed to timely identify, assess, and provide pressure ulcer treatments to one of three residents (Resident R22), which resulted in actual harm to Resident R22, who developed a facility acquired Stage 4 pressure ulcer on the left gluteal fold/thigh. Findings include: Review of facility Policy entitled Skin Integrity and Wound Management with effective date: July 1, 2001, and review and revision date of September 1, 20212, revealed the following: The facility staff will continually observe and monitor patients for changes and implement revisions to the plan of care as needed. […]

• No harm, potential for more than minimal, widespreadF812Nov 16, 2021

  Based on observation of the food and nutrition department, reviews of essential equipment maintenance reports and interviews with staff, it was determined that the facility failed to ensure that the dish machine in the dietary department was working properly. Findings include: Reviews of the dish washer repairs and maintenance records dated November 4 and 8, 2021 revealed that the dish machine located in the main kitchen of the food and nutrition department had been serviced for a missing conveyor paw on November 4, 2021, and serviced on November 8, 2021, for a broken conveyor. Observations made in the presence of the Regional Food Service Director, Employee E27, at 1:30 p.m. […]

• No harm, potential for more than minimal, patternF689Apr 16, 2026

  Based on observation, clinical record review and staff interview, it was determined that the facility failed to ensure that supervision was provided to one of 30 residents reviewed (Resident R4) and the safe temperature of hot beverages in one of three nursing floors (Third Floor)Findings include: Review of Resident R4's clinical records revealed that the resident was admitted to the facility on [DATE], the diagnoses of Impulse Disorder, Dementia (Progressive cognitive decline), Abnormal Gait/Mobility (Unsteady walking pattern). Review of Resident R4's April 2026 physician orders revealed an order obtained March 1, 2026, for one-to-one supervision, at all times, every shift. […]