Hillcrest Nursing and Rehabilitation Community

In the surveyor’s words

From the most serious findings on record at Hillcrest Nursing and Rehabilitation Community, in the surveyor’s own words.

• Actual harm, isolatedF689Mar 28, 2025

  This citation refers to intake MI00151516. Based on observation, interview and record review, the facility failed to implement the hot liquid policy for 1 resident (R1) of 4 residents reviewed, resulting in second degree burn caused by a hot liquid spill. Findings include: A second-degree burn is deeper than the top layer of skin (through epidermis to the dermis) and causes a blister to form with pink, painful skin. The blister may break and leak clear fluid, there is risk of infection. […]

• Actual harm, isolatedF689Mar 11, 2024

  Based on observations, interviews and record review, the failed to provide adequate supervision to prevent falls for 3 Residents (R1, R2, and R3) of 3 residents reviewed for falls, resulting in R1 falling and sustaining a hip fracture and the potential for R2 and R3 to sustain serious injuries. Findings included: R1 Review of R1 face sheet, no date, revealed she was a [AGE] year-old female admitted to the facility on [DATE] and had diagnoses that included: cerebral infarction (stroke), vascular dementia, psychotic disturbance, mood disturbance, anxiety, need for assistance with personal care, muscle weakness, difficulty in walking, cognitive communication deficit, syncope (fainting) and collapse. […]

• Actual harm, isolatedF684May 5, 2023

  This citation has two Deficient Practice Statements (DPS) DPS A This citation pertains to Intake MI00126689 Based on observation, interview and record review, the facility failed to plan and implement comprehensive medical care for a one Resident (R12), resulting in a decline in physical and mental well-being, pain, and the potential for all facility residents to not receive quality care. Findings: Review of the Electronic Medical Record (EMR) reflected R12 originally admitted to the facility 2/23/23 with diagnoses that included End Stage Renal Disease and Respiratory Failure. Review of the Minimum Data Set (MDS) dated [DATE] reflected a Brief Interview for Mental Status (BIMS) score of 13 which indicated mild cognitive impairment. […]

• Actual harm, isolatedF725Oct 5, 2022

  Based on observation, interview, and record review, the facility failed to provide staffing levels to meet the needs of 4 resident's (Resident #1, Resident #21, Resident #26, and Resident #18), resulting in (a) Resident #1 laying in feces and urine for hours and not being repositioned, (b) Resident #21 being left in the same position in a wheelchair for multiple hours at a time and redeveloping a previously healed pressure area on the left buttock, (c) R26 being left soiled for extended periods of time and delays in staff availability to transfer R26 in or out of bed, and (d) Resident #18 sitting in a urine soaked brief and staff not responding to the residents needs for an extended period of time. […]

• Actual harm, isolatedF689Aug 31, 2022

  Based on interview and record review, the facility failed to prevent falls for 2 residents (Resident #1 and Resident #3) when care planned interventions were not implemented, resulting in the 1.) The potential for serious injury when Resident #3 was transferred incorrectly 2.) Cervical Spine (neck) fracture after Resident #1 fell from her bed onto the floor when care planned interventions were not in place. Findings: Review of a facility policy Fall Prevention and Management Policy revised 1/2022 reflected the purpose of the policy was to Assess resident risk for falls and implement interventions to reduce the incidence of falls and/or to mitigate the risk of injury related to falls. […]