Signature Healthcare at Hillcrest

In the surveyor’s words

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

• Actual harm, isolatedF657Aug 10, 2021

  Based on interview, record review and facility policy review, it was determined the facility failed to ensure the Comprehensive Care Plans were reviewed and revised after each Minimum Data Set (MDS) Assessment or a change in condition for three (3) of three (3) sampled residents (Residents #1, #2 and #3). The facility failed to revise Resident #1, #2 and #3's Comprehensive Care Plan to include the facility's MDS Assessments for two (2) staff assist during bathing and the use of the shower bed. On 02/26/2021, Resident #1 rolled from the shower bed landing onto the floor resulting in a Subdural Hematoma, Closed Bicondyle Fracture of the Right Femur and a six (6) centimeter Laceration of the Frontal Scalp without Foreign Body that required (9) nine staples. […]

• Actual harm, isolatedF689Aug 10, 2021

  Based on interview, record review, facility policy review, and manufacturer guideline review, it was determined the facility failed to ensure one (1) of three (3) sampled residents (Resident #1) received adequate supervision and assistance to prevent accidents. On [DATE], Resident #1 fell from a shower bed (gurney) while being assisted by one (1) Certified Nursing Assistant (CNA) during a shower, requiring Resident #1 to be transferred to an acute care facility for evaluation and treatment. Resident #1's fall from the shower bed (gurney) resulted in a six (6) centimeter long scalp laceration that required nine (9) staples, a Subdural Hematoma, and a Closed Bicondyle Fracture of the Right Femur. […]

• Actual harm, isolatedF908Aug 10, 2021

  Based on interview, record review, and review of facility policy, it was determined the facility failed to ensure a shower bed was maintained in safe operating condition and documentation of preventative maintenance (PM's) completed for resident care equipment for one (1) resident in a sample of three (3) residents (Resident #1). On [DATE], Certified Nursing Assistant (CNA) #1 was providing Resident #1 a shower in a shower bed (gurney). CNA #1 rolled Resident #1 to his/her side to remove clothing. The siderail of the shower bed broke and Resident #1 subsequently fell to the floor. […]

• No harm, potential for more than minimal, widespreadF812May 14, 2026

  Based on observation, interview, and facility policy review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety which had the potential to affect residents who consumed meals from the kitchen. Observation of the kitchen, on 05/12/2026 and 05/13/2026, revealed food items uncovered in the freezer, two staff members not wearing a hairnet as required, and alternative food item prepared for lunch service, left uncovered and temped at an unacceptable temperature range (81 Degrees Fahrenheit).Review of the facility's revised policy, titled, Food Preparation, dated 02/2026, revealed all foods were prepared in accordance with the Food and Drug Administration (FDA) Food Code. […]

• No harm, potential for more than minimal, widespreadF812Apr 18, 2025

  Based on observation, interview, and facility policy review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for all resident(s) in the facility. 1. Observation in the kitchen revealed staff with their hair nets not covering their hair as required. 2. Observation of the kitchen revealed multiple food items that were not covered in the freezer, food items in the refrigerator out of date per the manufacturer's use-by date. Continued observation revealed multiple food items dated with only a month and day and did not include the year for reference. Observation of metal pans revealed they were removed from cleaning and stacked without allowing sufficient dry time. […]