Hillcrest Retirement Village

In the surveyor’s words

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

• Actual harm, isolatedF689Feb 27, 2025

  Based on interview and record review the facility failed to ensure the safety of a resident. This failure resulted in R1 being found in bed with R1's left hip being internally rotated and later being diagnosed as a displaced left hip fracture. This applies to 1 of 3 residents (R1) reviewed for falls with injury in the sample of 3. The findings include: R1's Facesheet dated 2/26/25 shows R1 has diagnoses including, but not limited to, osteoarthritis, dementia, cataract, major depressive disorder, gastro-esophageal reflux disease, hyperlipidemia, and unspecified abnormalities of gait and mobility. R1's Minimum Data Set (MDS) dated [DATE] shows R1 required substantial/maximal assistance to sit upright from a lying position while in bed. […]

• Actual harm, isolatedF689Sep 25, 2024

  Based on observation, interview, and record review the facility failed to supervise a resident with a history of falls, failed to ensure a safe transfer was performed, and failed to review/revise fall interventions post fall for 3 of 24 residents (R114, R23, R93) reviewed for safety in the sample of 24. This failure resulting in R114 sustaining a right hip fracture and R23 sustaining a head wound. The findings include: 1. On 09/23/24 at 10:54 AM, R114 was sitting in his wheelchair, in the activity room by nurses station. R114 was unable to answer any questions. The facility's Reporting to IDPH worksheet dated 6/25/24 shows fall with injury-R114 was sent to hospital for evaluation and treatment of bruising to right groin. […]

• Actual harm, isolatedF684Feb 20, 2024

  Based on interview, and record review the facility failed to ensure a nurse reported a potential injury promptly to another nurse or physician. This applies to 1 of 3 (R1) residents reviewed for quality of care in the sample of 10. This failure resulted in R1 experiencing a delay in care/assessment and experiencing increased pain. The findings include: On 2/20/2024 at 10:56AM, V5 Registered Nurse (RN) said on 1/27/2024 she could see [R1's] right foot stuck behind the front wheel of the wheelchair. V5 said [R1] did say oww while her foot was stuck behind the wheel. V5 said [R1] did complain of pain upon palpation of the leg. V5 said she did not see any swelling at that time. V5 said she moved [R1] down to the nurse's station she was working at to watch the patient. […]

• Actual harm, isolatedF689Feb 20, 2024

  Based on interview and record review the facility staff failed to safely transport a resident in a wheelchair for 1 of 3 (R1) residents in the sample of 10 reviewed for accidents/incidents. This failure resulted in R1 experiencing a femur fracture. The findings include: On 2/20/2024 at 11:12AM, V7 Certified Nursing Assistant (CNA) said on 1/27/2024 she was in a resident's room when she heard the door alarm going off. V7 said she left the residents room and saw [R1] trying to leave the facility out the back door. V7 said she approached [R1] to prevent her from going outside because it was cold and icy that day. V7 said [R1] became agitated and began hitting her. V7 said she was able to turn around [R1's] wheelchair and started pushing her down the hallway. […]

• Actual harm, isolatedF600Dec 5, 2022

  Based on observation, interview, and record review, the facility failed to ensure a resident was free from physical abuse. This failure resulted in R1 being punched in the face by staff and sustaining a right eye contusion and right eye laceration requiring stitches. This applies to 1 of 4 residents (R1) reviewed for abuse in the sample of 4. The findings include: The facility's undated Final Incident Investigation Report documents on 11/29/22 at approximately 7:50 PM, [V4 (Terminated CNA)] notified the nurse [V3 (LPN)] that he and [R1] had an altercation and [V4] struck [R1] in the face and he was bleeding. [V4] was attempting to assist [R1] to bed for the night. When [V4] attempted to remove his pants [R1] became verbally and physically aggressive towards [V4]. […]