Hillcrest Health Care Center

In the surveyor’s words

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

• Immediate jeopardy, patternF805Jan 31, 2024

  Based on observations and diet orders the facility failed to assure the food was prepared and appropriate to meet resident's needs according to their assessment, diet orders and care plan. Observations determined that 5 residents, (Residents #11, #15, #26, #27 and #34) did not get the food in their ordered texture and 3 of the 5 residents that have an order for an altered diet are identified as moderately impaired cognition and 1 resident did have an episode of choking from being served the incorrect diet on 10/14/23. […]

• Immediate jeopardy, isolatedF805Jul 28, 2024

  Based on observations and diet orders the facility failed to assure the food was prepared and appropriate to meet resident's needs according to their assessment, diet orders and care plan. Observations determined that 3 residents did not get the food in their ordered texture and 2 of the 3 residents have an order for an altered diet and are identified as moderately impaired cognition, (Resident #5, #6 and #7). This failure resulted in residents receiving Immediate Jeopardy to the health, safety, and security of the resident. The State Agency informed the facility of the Immediate Jeopardy (IJ) that began as of July 25, 2024 on July 26, 2024 at 4:07 p.m. The Facility Staff removed the Immediate Jeopardy on July 26, 2024 through the following actions: a. […]

• Actual harm, isolatedF600Mar 26, 2026

  Based on clinical record review, facility record review, resident and resident family interviews, staff interviews and facility policy the facility failed to appropriately implement interventions to protect 2 out of 3 residents (Resident #3 and #50) reviewed from abuse. The facility reported a census of 57 residents.Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #3 documented diagnoses of muscle weakness, stroke and diabetes mellitus. The MDS showed the Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. […]

• Actual harm, isolatedF684Sep 27, 2022

  Based on clinical record review, staff interview, and facility policy/procedure the facility failed to assess, document, notify the provider and family and provide skin assessments and complete neurological assessments for three of three residents reviewed after post falls/injuries. (Resident #4, #5, #12). Resident #4 was transferred to the local clinic on 3/1/22, where it was determined that sutures had to be utilized to connect the skin on the residents right hand from a fall that occurred on 2/28/22. The facility reported a census of 47 residents. Findings include: Review of a the facility policy and procedure for change of condition reporting dated 7/2021, instructed: Acute Medical Change- 1. […]

• No harm, potential for more than minimal, widespreadF880Jan 31, 2024

  Based on observations, clinical record, facility policy, Centers for Disease Control and Prevention (CDC), and staff interviews, the facility failed to don and doff Personal Protection Equipment (PPE) correctly, dispose of PPE correctly, disinfect reusable PPE correctly, disinfect used laundry containers correctly, and perform hand hygiene in between assistance residents eat their meals. The facility reported a census of 42 residents. Findings include: 1. In a concurrent observation and interview on 1/22/24 at 11:22 AM of an uncovered red trash bin with a N95 mask in it along with other discarded PPE. A reusable PPE gown hung on Resident #17's outside room door. Staff R, Certified Nurse Assistant (CNA) reported that someone must have left it there. […]