Hillcrest Home

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Jun 19, 2026

  Based on observations, interviews, facility documents, and policy review, it was determined that the facility failed to provide adequate supervision to prevent elopement for one (Resident #1) of three sample residents who were reviewed for accident and supervision. Specifically, facility staff failed to respond to an exit door alarm on a kitchen exit door, which allowed Resident #1, a cognitively impaired resident with a known history of wandering, to exit the facility unattended into an unsecured area without staff knowledge. The IJ began on 12/24/2025 at 6:14:PM, when Resident #1 eloped through the unsecure kitchen door without staff knowledge. […]

• No harm, potential for more than minimal, widespreadF812Oct 21, 2021

  Based on observation and interview, the facility failed to ensure 4 of 4 working ice machines were maintained in clean, sanitary condition to prevent potential illness or infection for residents who received meals or ice from the main kitchen and 4 household kitchens. These failed practices had the potential to affect all 92 residents, as documented on a list provided by Registered Dietitian on 10/21/21. The findings are: 1. On 10/18/2021 at 12:27 P.M., Dietary Employee (DE) #1 took a white napkin and wiped the top of the internal curtain in the main kitchen's ice machine. A black substance transferred onto the napkin. Using another napkin, the employee wiped the back side of the curtain. The napkin returned with a slimy, pinkish substance on it. […]

• No harm, potential for more than minimal, patternF609Jun 19, 2026

  Based on interviews, record review, and facility policy review, the facility failed to ensure an allegation of abuse were reported to the Administrator and the State Survey Agency (SSA) within the required timeframe for one (Resident #2) of three residents reviewed for abuse. Specifically, the facility received a report of alleged abuse involving Resident #2 on 10/23/2025 (reported by LPN #10 to the Administrator) but did not report the allegation to the SA until 06/19/2026. Additionally, it was revealed by the Clinical Coordinator that the facility received a report of abuse for Resident #2 on 11/17/2025, which was reported to LPN #9, who failed to report the allegation to the Administrator until 11/18/2025. […]

• No harm, potential for more than minimal, patternF677Mar 28, 2024

  Based on observation, interview, and record review, the facility failed to ensure that 2 (Residents #44, #78) sampled residents had facial hair and nails trimmed and re-polished. This has the ability to affect 16 residents who reside on 300 Hall. The findings are: 1. On 03/25/2024 at 11:48 AM, the Surveyor observed Resident #78 with chipped nail polish on the fingernails of both hands. The Surveyor ask Resident #78, Do you like your nails painted? Resident #78 stated, Yes, but they need repainted. 2. On 03/25/2024 at 03:09 PM, the Surveyor observed Resident #78 with chipped nail polish on both hands. 3. On 03/26/2024 at 09:19 AM, the Surveyor observed Resident #78 with chipped nail polish on both hands. 4. […]

• No harm, potential for more than minimal, patternF728Feb 17, 2023

  Based on interview, and record review, the facility failed to ensure full time Nursing Assistants (NA) did not work more than 4 months in the facility without completing the necessary certification requirements. This failed practice had the potential to affect 87 residents who currently resided in the home according to the Resident Census and Conditions of Residents provided by the Administrator on 02/14/23 at 8:50 AM. The findings are: 1. On 02/15/23 at 2:25 PM, the Human Resource (HR) Director provided a list of 16 Nursing Assistants who were currently employed by the facility. The Surveyor asked the HR Director if all of the Nursing Assistants listed had completed their testing within the specified 4 month time frame. She stated, No. […]