Hillcrest Heights Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, widespreadF584Sep 8, 2022

  Based on observations, interviews, and record reviews the facility failed to ensure the facility provided a safe, comfortable, and homelike environment when it did not ensure temperatures were within the required temperature range of 71 degrees - 81 degrees Fahrenheit (F) during an excessive heat wave [MEDICATION(S)] more than 7 days. The facility also failed to repair or replace inoperable roof mounted Air Conditioning (AC) units. As a result, 41 of 42 resident rooms (Rooms 20, 21 ,22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 34, 35, 36, 37, 38, 39, 40, 41, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62) were more than 81 F, and 13 of the 42 rooms (Rooms 20, 21, 23, 25, 26, 29, 56, 57, 58, 59, 60, 61, 62) were between 90 F - 99 F. […]

• No harm, potential for more than minimal, widespreadF812Feb 1, 2024

  Based on observations, interviews and record reviews, the facility failed to ensure safe and sanitary measures were met in the kitchen during dietary operations according to standards of practice when: 1. The Cook (CK) 1 did not perform hand hygiene consistently during food preparation, 2. The Dietary Aide (DA) crossed over from dirty station to clean station while working in the dishwashing station, and 3. Cook (CK) 1 and the Dietary Assistant Manager (DAM) were unable to verbalize the cool down process. These failures had the potential to result in harmful bacteria growth and cross contamination that could lead to foodborne pathogens to come in contact with the residents' food and may cause food borne illness to the residents. The facility's census was 91. Findings: 1. […]

• No harm, potential for more than minimal, widespreadF865Sep 8, 2022

  Based on Interview and Record Review, the facility failed to ensure the Quality Assurance Committee developed a plan related to the repair of their Air Conditioning Units. As a result, the facility was unable to provide temperatures ranging from 71 - 81 degrees F per regulation to the residents during an excessive heat warning. Findings: On 9/1/22, the California Department of Public Health (CDPH) issued AFL (All Facilities Letter) 22-18 alerting all healthcare facilities of a Level II Extreme Heat Alert to have contingency plans in place to deal with the loss of air conditioning and take measures to ensure patients and residents are free of adverse conditions that may cause heat related health complications. […]

• No harm, potential for more than minimal, patternF755Jan 9, 2025

  Based on observation, interview, and record review, the facility failed to ensure the accountability of controlled medications (those with high potential for abuse and addiction) and failed to accurately and timely administer resident medications, when: 1. The Controlled Drug Records (accountability records) for four out of seven randomly selected residents (Residents 91, 86, 81, and 11) did not reconcile with the Medication Administration Records (MAR). This failure resulted in inaccurate accountability of controlled medications and the potential for accidental duplicate medication administration; and 2. The pharmacy did not provide Resident 30's Creon (brand name for pancrelipase, a medication for the pancreas) for 13 days. […]

• No harm, potential for more than minimal, patternF760Jan 9, 2025

  Based on interview and record review, the facility failed to ensure one of one resident (Resident 30) was free of a significant medication error when the facility did not give Creon (brand name for pancrelipase, a medication for the pancreas) to Resident 30 for 13 days. This failure resulted in Resident 30 having digestive symptoms and had the potential for worsening of her medical conditions. Findings: During an interview on 1/7/25 at 11:40 A.M., Resident 30 stated she had been discharged from the hospital two weeks ago with a new medication to take with meals for her pancreas. Resident 30 stated the hospital told her that her pancreas is failing and she needs to take a pancreas medication with breakfast, lunch, dinner, and snacks. […]