Hillcrest Commons Nursing & Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, patternF684May 11, 2021

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure care and treatments provided to Resident #1 were conducted in accordance with professional standards of practice. As a result of a transcription error, Resident #1 was administered medications, from another patients hospital discharge medication list, that were not listed on his/her Hospital Discharge Summary, daily in error during his/her entire length of stay at the Facility, which contributed to his/her change in his/her mental status, and his/her significant decline in condition. […]

• Immediate jeopardy, patternF758May 11, 2021

  Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), the Facility failed to ensure Resident #1 was free from the administration of unnecessary [CONDITION(S)] medications (medications that affect brain activity associated with mental processes and behavior). Upon admission to the Facility in January 2021, in addition to Resident #1 physician ordered medications, which include two [CONDITION(S)] medications, another patients hospital discharge medication list was included in Resident #1's Hospital discharge packet and as a result, three additional [CONDITION(S)] medications were ordered and administered, in error, to Resident #1 during his/her admission to the Facility, (for greater than 30 days). […]

• Immediate jeopardy, patternF760May 11, 2021

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure Resident #1 was free from significant medication errors, when he/she was administered six medications in error daily, for more than a month while in the Facility and the transcription error was not identified by the Facility until after Resident #1 was discharged from the Facility and readmitted to the Hospital. - On 01/05/21, upon Resident #1's admission to the Facility, along with a list of his/her discharge medications, there was a page containing another patients' hospital discharge medication list, with the other patients name clearly identified on the top of that page, the medications on that list were transcribed in error onto Resident #1's physician medications… […]

• Immediate jeopardy, isolatedF689Jan 27, 2022

  Based on records reviewed and interviews, for two of three sampled Residents (Resident #1 and Resident #2), the Facility failed to ensure the resident's environment was free from environmental hazards and failed to provide adequate supervision to ensure resident safety. - On 1/11/22 at approximately 10:15 A.M., Resident #1, who resided on the secured unit, ingested approximately 800 milliliters (ml) of an alcohol hand sanitizer (active ingredient [MEDICATION(S)] alcohol 70%). […]

• Immediate jeopardy, isolatedF689Dec 29, 2021

  Based on record review and interviews, for one of three sampled residents (Resident #1), the Facility failed to ensure his/her environment was free of hazards, and that his/her safety was maintained to prevent injury. On [DATE], during the night shift, Resident #1 displayed extreme self-injurious behavior by banging his/her head on a dining table in the day room. Resident #1, who was in a wheelchair, was left seated in front of the table and between 1:00 A.M. to 5:00 A.M., continued to forcefully and repeatedly bang his/her head on the table. […]