Hillcrest Home

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interview, clinical record review, and policy review the facility failed to protect residents from misappropriation of property when resident medication became missing from the facility for 2 of 2 residents reviewed (Resident #40 and Resident #49). The facility reported a census of 51 residents. Findings include:A Facility Self Report to the Department of Inspections, Appeals and Licensing (DIAL) by the Administrator on 6/21/26 at 3:50 p.m. revealed 54 doses of Hydromorphone (a highly potent, semi-synthetic opioid analgesic (narcotic) used to treat moderate to severe pain) for Resident #40 and on 6/26/26 13 doses of Hydrocodone (a potent, semi-synthetic opioid prescribed to manage severe chronic pain and suppress coughs) for Resident #49 was missing from the narcotic drawer in the medication cart. On June 20th, 2026 at approximately 7:30 p.m. Staff K, Certified Medication Aide (CMA) went to give Resident #40 his Hydromorphone out of the bubble pack per his request. Staff K noted the bubble pack…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, electronic health record (EHR) review, facility document review, policy review, and resident and staff interviews, the facility failed to consistently respond to activated call lights within a timely manner for 1 of 17 residents reviewed (Residents #47). The facility reported a census of 51 residents.Findings Include:Resident #47's Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating intact cognition. The MDS listed Resident #47 required partial/moderate assistance for toileting hygiene and for toilet transfers. The MDS included diagnoses of urinary tract infection, osteoporosis, hyperlipidemia, and renal insufficiency. The Care Plan Focus initiated 5/29/26 identified Resident #47 had impaired mobility. The Interventions included to ensure the call light was available to the resident and to evaluate the resident's ability to activities of daily living (ADLs) (everyday tasks).The Care Plan Focus initiated on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff and family interviews, and policy review the facility failed to make prompt efforts to resolve and investigate a complaint/grievance and actively work toward resolution for 1 of 1 complaint letters reviewed (Resident #2). The facility reported a census of 44 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #2 document a Brief Interview for Mental Status (BIMS) of 11 indicating she was moderately cognitively impaired. The MDS also documented she needed supervision or touching assistance with transfers, toileting, and walking. The MDS informed she had diagnoses of diabetes mellitus, heart failure, depression, anxiety, and a prognosis with a life expectancy of less than six (6) months to live. Record review of a letter to the facility dated 1/7/25 from Family Member #1 for Resident #2 informed the facility of the following concerns identified with the care of their loved one: a. Delay in receiving pain medication for Resident #2 when actively dying on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff and family interviews, and policy review the facility failed to promptly implement a new order for 1 of 3 residents reviewed for pain (Resident #2). The order given was to increase the dosage of as needed (PRN) Morphine (narcotic liquid pain medication) for an actively dying resident. The facility reported a census of 44 residents. Findings include: The Minimum Data Set (MDS) dated [DATE] for Resident #2 document a Brief Interview for Mental Status (BIMS) of 11 indicating she was moderately cognitively impaired. The MDS also documented she needed supervision or touching assistance with transfers, toileting, and walking. The MDS informed she had diagnoses of diabetes mellitus, heart failure, depression, anxiety, and a prognosis with a life expectancy of less than six (6) months to live. Record review of Resident #2 Controlled Drug Record for her morphine dated 12/21/24 documented the last dose of morphine at 0.25 mL was given on 12/22/24 at 1:30 PM. Record review of a document…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff, family, and provider interviews, and policy review the facility failed to obtain an order to increase an as need (PRN) morphine (liquid pain medication) order for 1 of 3 residents reviewed who was actively dying (Resident #2). The facility also failed to obtain orders prior to suctioning a resident during end of life cares for 1 of 1 residents (Resident #2). The facility reported a census of 44 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #2 document a Brief Interview for Mental Status (BIMS) of 11 indicating she was moderately cognitively impaired. The MDS also documented she needed supervision or touching assistance with transfers, toileting, and walking. The MDS informed she had diagnoses of diabetes mellitus, heart failure, depression, anxiety, and a prognosis with a life expectancy of less than six (6) months to live. Record review of Resident #2 discontinued, current, and completed morphine orders in her Electronic Health Record (EHR)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, clinical record review, staff interview, and policy review, the facility failed to provide services that met professional standards regarding following physician orders with insulin administration for 1 of 5 residents reviewed for medication administration (Resident #16). The facility reported a census of 45 residents. Findings include: The Minimum Data Set (MDS) assessment dated [DATE] for Resident #16 revealed the resident had a Brief Interview for Mental Status (BIMS) of 10 indicating moderately impaired cognition. The MDS further revealed the resident had a diagnosis of diabetes mellitus (DM) and had received insulin 7 out of the past 7 days. Review of physician orders for Resident #16 revealed an order for blood glucose four times a day related to diabetes mellitus. Physician orders further revealed an order for Humalog (insulin) 30 units subcutaneously (SQ) one time a day to be given at 7:30 AM and to hold the insulin if blood sugar is less than 120 with a start date of 3/14/24.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on personnel record review, staff interview, and policy review, the facility failed to ensure mandatory Dependent Adult Abuse training had been completed within 6 months of employment for 1 of 5 staff reviewed (Staff A). The facility reported a census of 45 residents. Findings include: Personnel record review for Staff A, Certified Nursing Aide (CNA) revealed a hire date of [DATE]. The personnel record revealed Staff A had previously completed Dependent Adult Abuse training [DATE] and it expired [DATE]. Staff A did not complete the mandatory training again until [DATE]. Review of facility policy titled, Abuse Prevention Policy, revised 9/2022 revealed employees will receive training as required by state and federal regulations. Employees and staff members, who are mandatory reporters of dependent adult abuse,shall be required to receive two hours of training related to the identification and reporting of dependent adult abuse within six months of hire, as a part of orientation training, and every three…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review, policy and procedure review, and staff interviews the facility failed to treat a resident with respect and dignity in a manner that promotes maintenance or enhancement of his or her quality of life for 1 out of 5 resident reviewed. (Resident #1). The facility identified a census of 47 residents. Findings include: The Minimum Data Set (MDS) for Resident #1, with an assessment reference dated 3/5/24, documented diagnoses which included hypertension, Non-Alzheimer's Dementia, anxiety, and repeated falls. The MDS revealed the resident with a Brief Interview for Mental Status (BIMS) score of 8, which indicated moderately impaired decision making abilities, has hallucinations and delusion, and required partial/moderate assistance with shower/bathing. The Plan of Care with an initiated date of 2/27/24, stated the resident had a functional performance self-care deficit related to dementia. Interventions include: Bathing/Showering: Resident is able to have a bath or shower. Bath days per Care Plan. Shower transfer EZ stand times 2 assist. Transfer/Ambulation:…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, facility policy and procedure, and staff interviews, the facility failed to follow physicians orders for 2 of 4 residents reviewed for medication administration. (Resident #3 and Resident #4). The facility reported a census of 47 residents. Finding include: 1. The Minimum Data Set (MDS) dated [DATE] revealed Resident #3 had a Brief Interview for Mental Status (BIMS) score of 15 for which indicated no cognitive impairments. The MDS indicated the resident had diagnoses which included hypertension, seizure disorder, and cyst of pancreas. The MDS also revealed the resident received a diuretic and an antiplatelet in the last 7 days. Resident #3 Care Plan initiated on 4/12/22 indicated the resident will be prescribed the minimum amount of medications necessary. The interventions with an initiate date of 10/5/22 directed staff to consult pharmacist to review medications, Resident prefers not to be woke up for medications between 10:00 p.m.- 6:00 a.m. and prefers to take medications in her room…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record review, Center for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) manual, and staff interview the facility failed to transmit a Minimum Data Set (MDS) discharge assessment record for 1 of 1 resident (Resident #12) reviewed. The facility identified a census of 51 residents. Findings include: An Electronic Health Record (EHR) Census Record Showed Resident #12 went to the hospital on paid leave on 7/26/22. A review of the EHR revealed MDS assessment records on 2/21/23 at 11:45 a.m. for Resident #12 had completed a 7/26/23 Discharge Return Not Anticipated Record in the EHR that had not been batched for submission to the CMS Quality Improvement and Evaluation System (QIES) Assessment and Submission and Processing (ASAP) system. The Discharge Return Not Anticipated Record had a completion date of 7/26/23 by the MDS Coordinator. During an interview on 2/22/23 at 1:27 p.m. the MDS Coordinator reported she tries to submit MDS records to the federal data base (QIES ASAP) system weekly. She reported Resident #12 had…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review, Center for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) manual, and staff interview, the facility failed to accurately code the Minimum Data Set (MDS) Assessments for 2 of 14 residents (Resident #36 and #159) reviewed. The facility identified a census of 51 residents. Findings include: 1. The Minimum Data Set (MDS) dated [DATE] for Resident #36 showed a Brief Interview for Mental Status Score of 15 indicating no cognitive loss. The MDS listed a diagnosis of type 2 diabetes without complications. The MDS in Section N0300 documented a O indicating no injections received during the 7 day look back period. Section N0350 was blank for insulin use. The MDS failed to document Resident #36 received insulin injections 7 days of the look back period from 2/10/23. A Medication Review Report signed by the Provider on 12/22/22 listed the following orders: a. Humalog Junior Kwik Pen Subcutaneous Solution Pen-Injector 100 units (U)/milliliter…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.