Hillcrest Health Care, LLC

In the surveyor’s words

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

• Immediate jeopardy, isolatedF684Feb 27, 2025

  Based on observation, interview, and document review the facility failed to identify a change in condition, comprehensively assess weight gain, monitor, and notify the physician for 1 of 1 residents (R1). As a result R1 had a total weight gain of 37 pounds over 13 days that resulted in heart attack, respiratory failure, and death. This resulted in a past non-compliance at an Immediate Jeopardy (IJ). The Immediate Jeopardy (IJ) began on [DATE] when R1 had a 7.1 pound (lb.) weight increase that was not reported to the physician nor comprehensively assessed and monitored. The Administrator and Director of Nursing (DON) were notified of the IJ on [DATE] at 5:48 p.m. […]

• Actual harm, isolatedF689Oct 17, 2024

  Based on observation, interview, and document review the facility failed to follow the care plan for safe transfers for a full body mechanical lift for 1 of 3 residents (R1) who required lifts for transfers. The facility's failures resulted in harm when R1 fell out of the lift and sustained subgaleal hematoma (bleeding between the skull and the scalp) and head laceration that required three staples. The facility implemented immediate corrective actions prior to survey and is issued at past non-compliance. […]

• Actual harm, isolatedF686Feb 18, 2022

  Based on observation, interview and document review, the facility failed to comprehensively assess and implement interventions to prevent worsening and prevent additional pressure ulcers (PU)'s from developing for 1 of 1 resident (R28) who had two unstageable PU's (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar) and one stage 2 PU (partial thickness skin loss of the dermis) This failure resulted in actual harm when R28's pressure ulcers worsened and additional PU's were acquired. Findings include: R28 was admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Observation and interview on 2/14/22, at 1:38 p.m. […]

• No harm, potential for more than minimal, widespreadF881Jun 13, 2024

  Based on interview and document review, the facility failed to implement a process for antibiotic review in order to determine appropriate indications, dosage, duration, trends of antibiotic use and resistance. This had the potential to affect any residents who had infections requiring antibiotic use. Findings include: When interviewed on 6/13/24 at 8:10 a.m., the director of nursing (DON), also identified as infection preventionist, indicated the facility uses McGeer's criteria but staff are not always completing that in the medical record and stated it is a team effort to monitor symptoms between nurse managers and herself. The DON indicated she has been doing infection prevention for the past year and when she started, they didn't even have a tracking form. […]

• No harm, potential for more than minimal, widespreadF812Jul 27, 2023

  Based on observation, interview and document review, the facility failed to follow manufacturers instructions for cleaning and sanitizing two ice machines used for resident consumption. This had the potential to affect all 59 residents who resided in the facility. Findings include: During an observation and interview on 7/24/23 at 8:18 a.m., culinary services director (CSD)-A stated the facility had two ice machines, one located in the kitchen and one in the adjacent dining room. CSD-A stated dietary staff cleaned the outside and maintenance staff deep cleaned the inside. CSD-A stated residents had the potential to consume ice from both ice machines. During document review, paper logs titled Ice Machine Cleaning indicated ice machines had been cleaned monthly in 2022 and 2023. […]