Hillcrest Home

In the surveyor’s words

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

• Actual harm, isolatedF689Feb 27, 2025

  Based on record review, staff and medical provider interviews, and policy review the facility failed to implement root cause analysis interventions for previous falls resulting in a fall with fracture, and to thoroughly assess a resident for possible injury after a fall for 1 of 3 residents reviewed for falls (Resident #1). The facility reported a census of 44 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #1 documented a Brief Interview for Mental Status (BIMS) of 4 indicating severe cognitive impairment. The MDS documented she was dependent on staff for eating, toileting, transferring, and does not walk. […]

• Actual harm, isolatedF658Apr 25, 2024

  Based on observation, record review, and staff interviews the facility failed to follow a physician order resulting in an emergency room visit for 1 out of 3 residents reviewed for medication administration (Resident #2). The facility reported a census of 47 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] revealed Resident #2 had a BIMS score of 10 which indicates moderate impairment of cognitive status. The MDS indicated she had hallucinations and verbal aggression directed toward others. The MDS revealed Resident #2 has diagnoses of Anxiety and Depression. On 4/24/24 at 8:49 AM observed Resident #2 sitting in her wheelchair in her room. She responded to the nurse knocking on her door and refused her medications. […]

• No harm, potential for more than minimal, patternF761Jul 2, 2026

  Based on observation, policy review, and staff interviews the facility failed to ensure all medications were dated when opened for six residents (Resident #23, #27, #31, #32, #44, and Resident #52). The facility reported a census of 51 residents. Observation on 7/1/26 at 4:08 p.m. revealed the medication cart contained the following medications stored and ready for use: Resident # 23, an open bottle of Latanoprost Ophth lacked an open date. Resident #27, an open bottle of Fluticasone Spray 50 microgram (mcg) lacked an open date. Resident #27, an open bottle of Dorzolamide Solution 2% lacked an open date. […]

• No harm, potential for more than minimal, isolatedF602Jul 2, 2026

  Based on staff interview, clinical record review, and policy review the facility failed to protect residents from misappropriation of property when resident medication became missing from the facility for 2 of 2 residents reviewed (Resident #40 and Resident #49). The facility reported a census of 51 residents. Findings include:A Facility Self Report to the Department of Inspections, Appeals and Licensing (DIAL) by the Administrator on 6/21/26 at 3:50 p.m. revealed 54 doses of Hydromorphone (a highly potent, semi-synthetic opioid analgesic (narcotic) used to treat moderate to severe pain) for Resident #40 and on 6/26/26 13 doses of Hydrocodone (a potent, semi-synthetic opioid prescribed to manage severe chronic pain and suppress coughs) for Resident #49 was missing from the narcotic drawer… […]

• No harm, potential for more than minimal, isolatedF637Jul 2, 2026

  Based on electronic health record (EHR) review, the Centers for Medicare and Medicaid Services (CMS) Long term Care (LTC) Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.20.1 October 2025, and staff interview the facility failed to complete a Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS) assessment after a resident discharged off hospice services for 1 of 2 residents reviewed on hospice services (Resident #22). The facility reported a census of 51 residents.Findings include:Resident #22's Clinical Census reviewed on 7/1/26 documented a change in primary payer from Hospice Medicaid to Medicaid primary payer effective 10/30/25.The MDS 3.0 Summary page in Resident #22's EHR revealed the facility failed to complete the SCSA MDS when hospice… […]