5 Reports
Inspection Report — Nov 13, 2025
Biennial Survey
Date: Nov 13, 2025
Visit Reason
The facility was surveyed as part of the biennial survey process to assess compliance with the Assisted Housing Program Licensing Rule.
Findings
The facility was found not in compliance with multiple sections of the Assisted Housing Program Licensing Rule, including medication storage, resident records, staffing requirements, resident assessments, service plans, dietary services, and physical plant requirements.
Deficiencies (11)
5(E)(3)(a): The facility did not maintain separate, clearly labeled cubicles or other physical means of separation for each resident’s medications, with Schedule II/controlled medications stored together without individual labeling.
8(A)(1)(b)(c)(d)(e)(f)(m): The facility failed to ensure required resident information was complete and maintained in individual resident records for 2 of 3 residents reviewed, missing dentist information, language spoken, marital status, date of admission, religious affiliation, and licensed practitioner contact details.
8(A)(2)(b): The facility failed to ensure that all personal property inventories included the date and signature of the resident or their legal representative for Residents #2 and #3.
9(F)(6): The facility failed to ensure current job descriptions in employee records accurately reflected assigned roles as Certified Residential Medication Aides for 3 of 5 employees reviewed, with files containing only CNA/PSS job descriptions.
13(B)(5)(6)(9)(10)(11)(13): The facility failed to assess a resident in multiple required areas including legal/financial assistance, functional abilities, health care coordination, transportation needs, community independence, and discharge planning for 1 of 3 residents reviewed.
13(C)(2): The facility failed to ensure residents or their legal representatives were actively involved in the development of service plans, evidenced by missing signatures for Residents #2 and #3.
13(C)(3): The facility failed to maintain documentation identifying who participated in the development of service plans and the ability and willingness of residents or legal representatives to participate for Residents #2 and #3.
13(C)(4): The facility did not ensure that a copy of the service plan was offered to the resident or legal representative, nor was documentation maintained for Residents #2 and #3.
13(C)(5)(b): The facility failed to include the frequency with which services would be provided in service plans for Residents #2 and #3.
15(F): The facility failed to ensure the diet manual was not more than five years old; the manual provided was from 2019 and no online resource was used.
16(F)(8): The facility failed to ensure bathroom doors had privacy locks; three bathrooms lacked interior locks on doors connected to bedrooms M26/M27, M30/M31, and M32/M33.
Report Facts
: 3
: 2
: 5
: 3
: 3
Inspection Report — Sep 12, 2025
Complaint Investigation
Date: Sep 12, 2025
Visit Reason
The inspection was conducted as a complaint investigation following reports of suspected violations of residents' rights involving two residents and an employee at HillHouse, a Level IV Residential Care Facility.
Complaint Details
The complaint investigation was substantiated with findings that Employee #1 used excessive force and physical restraint on Residents #1 and #2, and Employees #2 and #3 failed to report these incidents until several weeks later. Employee #1 resigned effective 9/8/25.
Findings
The investigation found that the facility failed to immediately report suspected violations of residents' rights and conduct of care for two residents. Employees witnessed use of excessive force and physical restraint but did not report these incidents promptly. Retraining and corrective actions were planned.
Deficiencies (1)
Failure to immediately report suspected violations of residents' rights and conduct of care for 2 residents.
Report Facts
Dates of incidents: 2
Retraining completion deadline: Nov 1, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #1 | Involved in use of excessive force and physical restraint; resigned effective 9/8/25 | |
| Employee #2 | Witnessed excessive force, failed to report incident promptly, retrained on 8/21/25 by RN | |
| Employee #3 | Witnessed physical restraint, failed to report incident promptly, retrained on 8/21/25 by RN |
Inspection Report — Aug 18, 2025
Complaint Investigation
Date: Aug 18, 2025
Visit Reason
The inspection was conducted as a complaint investigation regarding suspected violations of residents' rights and conduct of care at Hillhouse Inc., a Level IV Residential Care Facility.
Complaint Details
The complaint investigation involved suspected violations of residents' rights related to Employee #1's use of excessive force and physical restraint on Resident #1 and Resident #2. The incidents occurred on 7/27/2025 and 8/7/2025 but were not reported to management until 8/11/2025. The findings were substantiated based on record review and interviews.
Findings
The facility failed to immediately report suspected violations of resident rights involving use of excessive force and physical restraint by Employee #1 on two residents. These incidents were not reported to management until weeks after they occurred, violating mandatory reporting requirements.
Deficiencies (1)
Failure to immediately report suspected violations of resident rights or conduct of care to the Department of Health and Human Services as required.
Report Facts
Incident dates: Jul 27, 2025
Incident dates: Aug 7, 2025
Report date: Aug 11, 2025
Inspection Report — Nov 21, 2023
Biennial Survey
Date: Nov 21, 2023
Visit Reason
The inspection was a biennial survey to assess compliance with the Regulations Governing the Licensing and Functioning of Assisted Housing Programs for a Level IV Residential Care Facility.
Findings
The facility was found not in compliance due to improperly labeled medications on pharmaceutical containers for 2 out of 3 resident records reviewed, confirmed through record review, observation, and interviews.
Deficiencies (1)
Improperly labeled medications on pharmaceutical containers for Resident #1 and Resident #3.
Report Facts
Residents with medication labeling issues: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephen O. Schuchert | Administrator | Named in relation to the medication labeling deficiency and exit interview |
Inspection Report — Apr 25, 2023
Complaint Investigation
Date: Apr 25, 2023
Visit Reason
The inspection was conducted as a complaint investigation for multiple complaint cases numbered 2023-AHP-32880, 32881, 32896, 32939, and 32883.
Complaint Details
Complaint investigation related to cases 2023-AHP-32880, 32881, 32896, 32939, and 32883; no deficiencies noted indicating substantial compliance.
Findings
HillHouse, Inc., a Level IV Residential Care Facility, was found to be in substantial compliance with the Regulations Governing the Licensing and Functioning of Assisted Housing Programs: Level IV Residential Care Facilities Part of 10-144, Chapter 113.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Stephen O. Schuchert | Administrator | Named as the facility administrator in the report. |
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