Hillcrest Village

In the surveyor’s words

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

• Actual harm, isolatedF689Jan 13, 2021

  Based on observation, interview and record review, the facility failed to ensure a resident (Resident C) was provided adequate supervision and assistance of two staff members with bed mobility in accordance with the resident's assessment and care plan, which resulted in a right distal femur supracondylar (break of the bone at the knee) fracture after a fall out of bed, for 1 of 3 residents reviewed for accident hazards. Findings include: The clinical record for Resident C was reviewed on 1/21/21 at 12:54 p.m. [DIAGNOSES REDACTED]. The quarterly MDS (Minimum Data Set) assessment, dated 10/6/20, indicated intact cognition and required assistance of two staff members with bed mobility. […]

• No harm, potential for more than minimal, patternF842Apr 14, 2026

  Based on interview and record review, the facility failed to ensure medication administration records reflected the administration of narcotic pain medication (Residents C, D, E and F) for 4 of 5 residents reviewed for medical records. Findings include: 1. The clinical record for Resident C was reviewed on 4/13/26 at 11:06 a.m. The resident's diagnoses included, but were not limited to, osteomyelitis (bone infection) of the vertebra and necrotizing fasciitis (rapidly progressing bacteria infection). The physician's order, dated 3/24/26, indicated the resident was to receive Oxycodone-Acetaminophen (narcotic pain medication) 5-325 mg (milligrams) every 4 hours as needed for pain. […]

• No harm, potential for more than minimal, patternF842May 2, 2025

  Based on interview and record review, the facility failed to ensure residents' (Resident C, Resident D and Resident E) medication administration records accurately reflected the administration of narcotic medications for 3 of 4 residents reviewed for documentation. Findings include: 1. The clinical record for Resident C was reviewed on 5/1/25 at 2:52 p.m. The resident's diagnoses included, but were not limited to, anxiety, diabetes and chronic pancreatitis. The April 2025 medication administration record (MAR) indicated the resident was to receive Xanax (narcotic anti-anxiety medication) 0.25 mg (milligrams) twice daily at 8:00 a.m. and 8:00 p.m. […]

• No harm, potential for more than minimal, patternF580Nov 8, 2024

  Based on interview and record review, the facility failed to ensure the physician was notified when a resident's (Resident B) blood pressure was not within set parameters for 1 of 3 residents reviewed for notification of change in condition. Findings include: The clinical record for Resident B was reviewed on 11/6/24 at 10:34 a.m. The resident's diagnoses included, but were not limited to, hypertension and left sided hemiparesis (a condition that causes paralysis or weakness on one side of the body)/hemiplegia (one-sided muscle paralysis or weakness) secondary to cardiovascular accident. Review of the resident's vital signs report on 11/7/24 at 2:40 p.m. […]

• No harm, potential for more than minimal, patternF554Dec 14, 2023

  Based on observation, record review, and interview, the facility failed to ensure appropriate oversight of medication administration during 5 of 25 random observations. (Residents 104, 12, 98, 134, and 97) Findings include: 1. During an observation on 12/11/23 at 9:05 a.m., Resident 104 was resting abed, finishing her breakfast. There was a medication cup containing 1 clear yellow capsule, 1 red oblong capsule, 1 small green oblong tablet, 1 white round scored tablet, 1 white round unscored tablet, 1 large white oblong tablet, and 1 small pink oval tablet. The nurse was not within sight. During an interview on 12/111/23 at 9:06 a.m., Resident 104 indicated the pills in the cup were her morning medications. Staff typically left her medication on the table. […]