Hillcrest Health & Rehab

In the surveyor’s words

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

• Actual harm, isolatedF686Dec 30, 2025

  Licensure Reference Number NAC 175 12-006.09(H)(iii)(1) and 12-006.09(H)(iii)(2). Based on observation, interview and record review the facility failed to implement interventions for the prevention of pressure ulcers for 2 (Resident 2 and 4) of 4 residents sampled and failed to provide practitioner ordered wound care to promote healing of pressure ulcers for 1 (Resident 4) of 4 residents sampled. The facility census was 121. The findings are:Record review of the facility policy dated 07-25-2025 revealed all team members are responsible for preventing, caring for and providing treatment for any patient with altered skin integrity. […]

• Actual harm, isolatedF684Sep 3, 2025

  Based on record review and interview, the facility failed to evaluate change of condition for 1 [Resident 3] of 3 sampled residents. The facility had a total census of 119. Findings are:A. A review of Resident 3's admission Record revealed Resident 3 was admitted to the facility on [DATE] with a diagnosis of infection and inflammatory reaction due to internal right hip prosthesis, chronic systolic heart failure [a condition in which the heart muscle is weakened and cannot pump blood effectively], and presence of prosthetic heart valve. A review of Resident 3's Progress Note dated 8/22/25 revealed Brief Interview for Mental Status [an evaluation of cognitive status] score of 11. […]

• Actual harm, isolatedF689Mar 11, 2025

  Licensure reference: 175 NAC 12-006.09(I)(i)(1) Based on observation, interview, and record review, the facility failed to ensure fall prevention interventions were implemented for 2 [Residents 4 and 7] of 4 sampled residents with falls. The facility had a total census of 142 residents. Findings are: A. A review of Resident 4's Admission Record revealed Resident 4 was admitted to the facility on [DATE] with a diagnosis of displaced fracture of lateral end of right clavicle and acute respiratory failure with hypoxia. Admission Record indicated Resident 4 was discharged to an acute care hospital on 2/27/25. […]

• No harm, potential for more than minimal, widespreadF812Jun 4, 2026

  Licensure Reference Number 175 NAC 12.006.11(E) Based on observation, interview, and record review, the facility failed to ensure all food stored in the facility's kitchen was labeled, dated, and/or sealed, ensure kitchen was maintained in a clean and sanitary manner, ensure food holding temperatures (temps) were completed prior to food service all to prevent foodborne illness. The facility failed to ensure food temperature probes were sanitized between product usage, ensure staff washed hands between glove changes, and failed to ensure tongs were stored in a manner to prevent cross contamination. This had the potential to affect 118 residents that consumed food prepared in the facility kitchen. The total facility census was 120. […]

• No harm, potential for more than minimal, widespreadF865Jun 4, 2026

  Licensure Reference Number 175 NAC 12-006.07(C) Based on record review and staff interviews; the facility Quality Assessment Performance Improvement Plan (QAPI) failed to identify issues relevant to F 553, F 578, F 580, F 628, F 641, F 656, F 684, F689, F692, F 695, F 698, F 757, F 812, F 842, F 880 and implement plans of action to identify and correct the deficient practice. This deficient practice had the potential to affect all residents who reside in the facility. The facility sample size was 51. The facility staff identified a census of 120. Findings are:Record review of the facility QAPI program policies dated 01/01/2026 revealed the following information: Policy: The purpose of the Quality Assurance and Performance Improvement (QAPI)program is to ensure person-centered care. […]