Hillcrest Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF678May 8, 2025

  Based on record review and staff interview, the facility failed to ensure Cardio-Pulmonary Resuscitation (CPR) interventions were initiated and continued until the arrival of emergency medical personnel for a resident observed with absence of vital signs with a Full Code status, resulting in death for one (1) of two (2) residents reviewed for death in the facility. This had the potential to affect all residents in the facility with a Full Code status. This immediate jeopardy began on [DATE] at approximately 3:00 AM when Resident #194 was observed with absence of vital signs. LPN #125 and Nurse Aide #126 reportedly initiated CPR but discontinued it prior to the arrival of EMS. The facility Administrator was informed of the Immediate Jeopardy (IJ) tag on [DATE] at 2:55 PM. […]

• Actual harm, isolatedF689May 8, 2025

  Based on record review and staff interview the facility failed to provide adequate supervision to prevent avoidable accidents. This failed practice caused harm to Resident #245. Resident #245 fell from the shower bed and received hematoma and laceration to the head requiring sutures. The incident was corrected and will be sighted at past non-compliance. This failed practice was found true for (1) one of (6) six residents reviewed for accidents during the Long-Term Care Survey Process. Resident identifier: #245. […]

• No harm, potential for more than minimal, patternF657Jun 25, 2026

  Based on resident interviews, record review, and staff interview, the facility failed to include residents in their care plan meetings and ensure care plans were reviewed at least quarterly. Furthermore, the facility failed to revise the care plan for Resident #71's dentures. This was true for three (3) of five (5) residents sampled for care planning during the Long-Term Care Survey process. Census: 89 Resident identifier: #88, #71, #9a) Resident #71 During an interview on 06/22/26 at 12:16 PM, Resident #71 stated she had not been invited to attend care plan meetings. Review of Resident #71's medical records showed a care plan meeting had been held on 03/13/25 and the resident had attended. However, no further care plan meetings were documented since then. […]

• No harm, potential for more than minimal, patternF804May 8, 2025

  Based on observation and staff interview the facility failed to provide food that was palatable by serving scorched beans. This was a random opportunity of discovery had had the potential to affect a limited number of residents residing in the facility. Facility census: 90 Findings include: 04/15/25 01:40 PM the beans had a strong smoky smell and had small bits of black burnt substance in them. When tasting them they had an overcooked burnt taste to them. 04/15/25 01:55 PM The Culinary Account Manager (CAM) #101 stated the beans were cooked today and knew they were scorched. CAM #101 stated, Yeah she (the cook serving) scrapped the bottom of the pan. This confirmed the beans had been scorched and should not have been served.

• No harm, potential for more than minimal, patternF880May 8, 2025

  Based on observation, record review, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Resident identifiers: #29, #19, #17, #28, and #43. Facility census: 90. Findings included: a) Resident #29 On 04/16/25 at 8:45 AM, medication administration by Registered Nurse (RN) #12 to Resident #29 was observed. Resident #29 was ordered fluticasone nasal spray and allergy eye ophthalmic solution. RN #25 took the fluticasone nasal spray bottle out of the medication cart. She left the box for the nasal spray in the medication cart. […]