Hillcrest Manor Nursing Center

In the surveyor’s words

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

• Actual harm, isolatedF657Apr 4, 2025

  Based on record review and interview, the facility failed to ensure a resident's care plan was updated to include an intervention to prevent an identified pattern of falls for 1 (#39) of 2 sampled residents reviewed for accidents. The DON stated 54 residents at the facility had care plans. Findings: A facility policy titled Care Plans, Comprehensive Person-Centered, dated December 2016, read in part, The Interdisciplinary Team (IDT), in conjunction with the resident and/or their family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. A progress note, dated 08/12/24 at 2:30 a.m., showed Res #39 had fallen while attempting to go to their bathroom. […]

• Actual harm, isolatedF689Apr 4, 2025

  Based on record review and interviews, the facility failed to ensure staff provided supervision to prevent falls which resulted in a fracture for 1 (#39) of 2 sampled residents who were reviewed for accidents. The DON stated 54 residents resided at the facility. Findings: A facility policy titled, Fall and Fall Risk, Managing, dated March 2018, read in part, Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try and minimize complications from falling. […]

• No harm, potential for more than minimal, widespreadF554Apr 4, 2025

  Based on observation, records review, and interview, the facility failed to ensure a resident who self-administered their medication had been assessed for the ability to safely administer to do so for 1 (#13) of 9 sampled residents observed during medication administration observations. The DON stated one resident had self-administered medication at the facility. Findings: On 04/03/25 at 12:49 p.m., RN #1 was observed pre-setting an injector of insulin for Res #13. RN #1 was observed entering the resident's room and handing the insulin injector to the resident who raised their blouse, pushed the injector against their abdomen and pushed the button to release the insulin. The resident did not look to check the dose set on the injector prior to administering. […]

• No harm, potential for more than minimal, patternF623Apr 4, 2025

  Based on record review and interview, the facility failed to ensure a resident was provided a written notice of transfer prior to being transferred to a hospital for 1 (#33) of 2 sampled residents reviewed for hospitalizations. The DON stated 54 residents resided in the facility. Findings: A progress note, dated 02/15/25 at 9:51 a.m., showed the facility initiated a transfer to a hospital for Res #13. A progress note, dated 03/16/25 at 12:36 p.m., showed the facility initiated a transfer to a hospital for Res #13. On 04/04/25 at 11:58 a.m., LPN #3 stated they had been on duty on 02/15/25 and was the nurse who transferred Res #33 to a hospital that day. When asked about what documentation was sent with the resident they stated that such items as code status, orders and face sheet. […]

• No harm, potential for more than minimal, patternF758Apr 4, 2025

  Based on record review and interview, the facility failed to ensure: a. a psychotropic medication had an appropriate diagnosis for 1 (#50), and b. the physician addressed a GDR for 1 (#39) of 5 residents sampled for unnecessary medications. The DON reported nine residents received antipsychotic medications. Findings: A facility policy titled Antipsychotic Medication Use, dated December 2016, read in part, Residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. 1. […]