Hillcrest Rehabilitation & Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, widespreadF607Jan 10, 2024

  Based on review of policies, clinical records, and facility investigation documents, as well as staff interviews, it was determined that the facility failed to follow its abuse policy regarding the immediate suspension of an involved staff member from their duty pending a full investigation, putting all of the residents in danger of being abused, resulting in Immediate Jeopardy to their physical safety. Findings include:A review of the personnel file for Registered Nurse 6 revealed that she was hired as the facility's Assistant Director of Nursing (ADON) on [DATE], and worked in that position until she quit on February 28, 2022.The facility's policy regarding abuse, dated [DATE], indicated that all reports of resident abuse, neglect, exploitation, misappropriation of resident property,… […]

• Immediate jeopardy, patternF684Sep 1, 2021

  Based on facility policy, clinical records and staff interviews, the facility failed to notify physicians of elevated Capillary Blood Glucose (CBG) levels, failed to assess residents for [CONDITION(S)] (high blood glucose) and failed to educate staff on facility policies related to [CONDITION(S)] for six of 12 Residents (Residents R1, R2, R4, R7, R8, and R9), resulting in immediate jeopardy and harm which resulted in a resident being found unresponsive and not breathing, Cardiopulmonary Resuscitation (CPR) being initiated by staff, resident being transported to the emergency department by emergency medical services and death occurring to one of six residents (Resident R1). […]

• Actual harm, isolatedF600Jun 5, 2025

  Based on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to provide goods and services resulting in neglect that resulted in the actual harm of a left hip fracture for one of five residents (Resident R1). Findings include: Review of the facility policy, Identifying Types of Abuse dated 2/20/25, indicated that residents have the right to be free of neglect. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Review of Libre Texts Medicine procedure 12.8.5: Procedure- Turning and Positioning the Patient in Bed, indicated to position yourself on the side of the bed that the patient will be turned to. […]

• Actual harm, isolatedF689Jun 5, 2025

  Based on review of facility policy, clinical records and staff interviews, it was determined that the facility failed to make certain each resident received adequate supervision and assistance to prevent accidents which resulted in actual harm of a left hip fracture for one of five residents (Resident R1). Findings include: Review of the facility policy Accidents and Incidents-Investigating and Reporting dated 2/20/25, indicated all accidents occurring on our premises must be investigated and reported to the administrator. […]

• Actual harm, isolatedF600Oct 12, 2021

  Based on resident interviews, review of clinical records, review of facility policies and facility provided documentation, and interviews with staff, it was determined that the facility failed to protect residents from staff initiated sexual abuse. This failure resulted in actual psychosocial harm to three residents for three of four residents reviewed (Resident R1, R2, and R3). Findings include: A review of facility Abuse Policy, dated 1/11/21, updated 9/8/21, indicated that residents have the right to be free from abuse. […]