Hillcrest Health and Rehabilitation Center

In the surveyor’s words

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

• Actual harm, isolatedF656Mar 4, 2021

  Based on observation, interview, record review and a review of the facility policy it was determined the facility failed to implement the comprehensive person-centered care plan developed for two (2) of three (3) sampled residents (Resident #2 and Resident #3) consistent with resident's needs. The facility assessed and determined Resident #2 required assistance for ambulation in the facility to minimize the risk of the resident sustaining falls and injuries. However, the facility failed to ensure all staff were knowledgeable regarding the resident's assessed needs and failed to ensure the intervention of assisting the resident with ambulation, which was detailed on the resident's Kardex, was implemented. […]

• Actual harm, isolatedF689Mar 4, 2021

  Based on observation, interview, record review and review of facility policy it was determined the facility failed to ensure two (2) of three (3) sampled residents (Resident #2 and Resident #3) received adequate supervision to prevent accidents and falls were thoroughly investigated. The facility assessed Resident #2 as cognitively impaired, unsteady, and required extensive assistance of one (1) staff member for transfers and ambulation. The facility failed to identify Resident #2 had been assessed to require the assistance of staff for transfers and ambulation and allowed Resident #2 to ambulate unsupervised around the facility. Resident #2 experienced six (6) falls from 11/11/2021 through 02/28/2021, as a result of the falls the resident sustained [REDACTED]. […]

• No harm, potential for more than minimal, patternF880Mar 4, 2021

  Based on observations, interviews, and record review, the facility failed to identify and isolate residents to properly prevent the spread of COVID-19 for two (2) of three (3) sampled residents. (Resident #2 and Resident #3). Observations and interviews revealed the facility failed to isolate Resident #2 and Resident #3 after returning to the facility from emergency room (ER) visits as outlined in the facility's policy. Observations also revealed housekeeping staff failed to don appropriate Personal Protective Equipment (PPE) when cleaning an isolation room on 03/03/2021. […]

• No harm, potential for more than minimal, isolatedF600Aug 22, 2025

  Based on interview, record review, facility document review, and facility policy review, the facility failed to protect the residents' right to be free from abuse other residents for 2 (Resident #10 and Resident #38) of 5 residents reviewed for abuse.Findings included: A facility policy titled, “Abuse, Neglect, Misappropriation and Exploitation Policy,” revised 01/2018, indicated, “Our facility does not condone or tolerate resident abuse (this includes verbal abuse, sexual abuse, physical abuse and mental abuse), neglect, misappropriation or exploitation under any circumstances by anyone, including staff members, other residents, consultants, volunteers, staff of other agencies serving or visiting the resident, family members, legal guardians, sponsors, friends, or other individuals.” 1. […]

• No harm, potential for more than minimal, isolatedF609Aug 22, 2025

  Based on interview, record review, document review, and facility policy review, the facility failed to ensure staff reported an allegation of abuse timely to the Director of Nursing and/or Administrator for 2 (Resident #38 and Resident #81) of 4 sampled residents reviewed for abuse.Findings included: The facility policy titled, “Abuse, Neglect, Misappropriation and Exploitation Policy,” revised 01/2018, indicated, “All allegations involving suspected abuse, neglect, misappropriation or exploitation including injuries of an unknown source or misappropriation of resident property shall be reported immediately, but not later 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events… […]