Inspection Reports for
Hill Crest Manor
801 SOUTH COLBY, HAMILTON, MO, 64644-8287
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
14 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
155% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
24
18
12
6
0
Occupancy
Latest occupancy rate
60% occupied
Based on a June 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 54
Deficiencies: 1
Date: Jun 27, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident eloping from the facility through an unsecured and unalarmed exit door on 6/7/25.
Complaint Details
The complaint investigation found that Resident #1 eloped on 6/7/25, exiting through a south exit door that was unlocked and whose alarm reset after closing. The resident was gone for about 20 minutes before being returned by a former employee. The resident had severe cognitive impairment and was at risk for elopement. The facility conducted an immediate investigation and implemented corrective actions.
Findings
The facility failed to ensure residents remained free from accident hazards when Resident #1 eloped through an unsecured exit door. The door alarm system was disengaged, allowing the resident to exit unnoticed. Corrective actions including new keypad installation, increased alarm audibility, staff training, and resident monitoring were implemented and completed by 6/10/25.
Deficiencies (1)
Failed to ensure residents remained free from accident hazards when one resident eloped through an unsecured and unalarmed exit door.
Report Facts
Census: 54
Distance traveled by resident: 0.33
Date of elopement incident: Jun 7, 2025
Date of corrective action completion: Jun 10, 2025
Daily door checks: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Discussed alarm system issues, daily door checks, and new keypad installation | |
| LPN (B) | Charge Nurse | Responsible for checking doors and investigating alarms during morning shift |
| Social Services Director | Provided information on elopement rarity, alarm improvements, and staff training | |
| Administrator | Confirmed resident did not sustain injuries and described facility door policies and interventions |
Inspection Report
Routine
Census: 58
Deficiencies: 5
Date: Jan 29, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with residents' rights, dignity, privacy, and care standards, including observations, interviews, and record reviews related to resident treatment and staff conduct.
Findings
The facility failed to honor residents' rights to a dignified existence and privacy, with multiple instances of staff entering rooms without knocking or announcing themselves, and concerns about staff behavior including yelling and rough treatment. Several residents required assistance with activities of daily living and had cognitive or physical impairments. The facility lacked consistent care planning regarding privacy and dignity, and there were issues with grooming and hair care services.
Deficiencies (5)
Failure to honor residents' right to a dignified existence and privacy, including staff entering rooms without knocking or announcing themselves.
Lack of care planning addressing residents' privacy and knocking prior to room entry.
Staff behavior including yelling at residents and discussing residents' conditions in hallways.
Inadequate assistance and verbal cues provided to residents with visual impairments during meals and care.
Residents not receiving regular haircuts or grooming; facility lacked set timelines for hair care.
Report Facts
Residents present: 58
Residents sampled: 15
Residents affected: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Entered resident rooms without knocking; yelled at Resident #21 during a spell | |
| CNA B | Entered resident rooms without knocking; acknowledged staff should knock and announce | |
| CNA C | Stated staff should knock and announce themselves before entering rooms | |
| CNA D | Entered resident rooms without knocking; stated staff should knock and announce themselves | |
| CMT A | Entered resident rooms without knocking; stated staff should knock and announce themselves | |
| Director of Nursing | Director of Nursing | Expected staff to knock and announce themselves prior to entering resident rooms; expected staff to explain care to visually impaired residents |
| Administrator | Administrator | Expected staff to knock and announce themselves prior to entering resident rooms; expected regular haircuts and grooming for residents |
Inspection Report
Routine
Census: 58
Deficiencies: 18
Date: Jan 29, 2025
Visit Reason
The inspection was conducted as a routine regulatory survey of Hill Crest Manor nursing facility to assess compliance with resident rights, care planning, medication management, safety, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to honor residents' rights to dignity and privacy, support resident self-determination, timely submission of MDS assessments, care plan involvement, medication management including anticoagulant monitoring, safe use of mechanical lifts and wheelchairs, food safety and handling, grievance process, employee background checks, and maintenance of equipment such as wheelchairs.
Deficiencies (18)
Failure to honor residents' rights to dignity and privacy, including staff entering rooms without knocking or announcing themselves.
Failure to support resident self-determination through honoring resident choices related to showers and food preferences.
Failure to act promptly and resolve resident grievances voiced during resident council meetings and failure to communicate resolution.
Failure to maintain a surety bond equal or greater than 1.5 times the average monthly balance of residents' trust fund accounts.
Failure to annually inform residents of their rights during resident council meetings.
Failure to provide accessible information about the State Long-Term Care Ombudsman program to residents.
Failure to ensure residents received mail on Saturdays.
Failure to ensure residents knew how to file grievances in writing, anonymously, and obtain written decisions.
Failure to verify employee disqualification list (EDL) and nurse aide registry checks prior to hire for multiple employees.
Failure to transmit Minimum Data Set (MDS) assessments within federally mandated timeframe for one resident.
Failure to hold care plan meetings quarterly or upon significant change and failure to involve residents or representatives in care planning.
Failure to obtain routine orders for PT/INR monitoring for resident on Coumadin and failure to monitor anticoagulant therapy appropriately.
Failure to assist resident in gaining access to vision services by not replacing missing prescription eyeglasses in a timely manner.
Failure to follow manufacturer guidelines when transferring resident with mechanical lift and pushing residents in wheelchairs without foot pedals.
Failure to ensure nurse aides met minimum qualifications including certification within four months of hire.
Failure to discard expired medications, label opened medications, prevent loose pills in medication carts, and prevent leaving medications at bedside.
Failure to prepare and serve food in accordance with professional standards including labeling, sealing, hand hygiene, temperature monitoring, and proper storage.
Failure to maintain resident wheelchairs in safe operating condition with intact arm rests.
Report Facts
Facility census: 58
Residents affected by dignity/privacy deficiency: 5
Residents affected by self-determination deficiency: 3
Residents affected by grievance deficiency: 11
Residents affected by rights notice deficiency: 11
Residents affected by Ombudsman info deficiency: 11
Residents affected by mail delivery deficiency: 58
Residents affected by grievance filing deficiency: 11
Employees with late or missing EDL checks: 5
Employees with missing CNA registry check: 1
Residents sampled: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Aide | Named in findings related to failure to knock before entering rooms and improper mechanical lift use |
| CNA B | Certified Nurse Aide | Named in findings related to failure to knock before entering rooms and improper mechanical lift use |
| CNA C | Certified Medication Technician | Named in findings related to medication administration and food handling |
| CNA D | Certified Nurse Aide | Named in findings related to failure to knock before entering rooms and wheelchair safety |
| CMT A | Certified Medication Technician | Named in findings related to mechanical lift use, medication administration, and food handling |
| Director of Nursing | Director of Nursing | Named in multiple interviews regarding expectations for staff and deficiencies |
| Administrator | Administrator | Named in multiple interviews regarding expectations for staff and deficiencies |
| Social Services Director | Social Services Director | Named in findings related to care plan meetings and eyeglasses replacement |
| Dietary Manager | Dietary Manager | Named in findings related to food safety and resident food preferences |
| Dietician | Dietician | Named in findings related to food safety and resident food preferences |
| Maintenance | Maintenance | Named in findings related to wheelchair repairs |
| Physical Therapy Assistant A | Physical Therapy Assistant | Named in findings related to wheelchair use and care planning |
| Business Office Manager | Business Office Manager | Named in findings related to employee background checks and surety bond |
| Regional Accounting Person | Regional Accounting Person | Named in findings related to employee background checks |
| Regional Nurse Consultant | Regional Nurse Consultant | Named in findings related to medication storage and labeling |
Inspection Report
Complaint Investigation
Census: 56
Deficiencies: 3
Date: Oct 29, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding failure to provide necessary personal hygiene care, including shaving, showers, and nail care, to dependent residents unable to perform activities of daily living independently.
Complaint Details
The investigation was complaint-driven, focusing on allegations that dependent residents were not receiving necessary personal hygiene care including shaving, showers, and nail care. The complaint was substantiated with findings of inadequate care and documentation.
Findings
The facility failed to ensure that dependent residents received adequate personal hygiene care, including shaving for one resident, showers for two residents, and nail care for one resident. Documentation and care plans were lacking, and scheduled showers and nail care were inconsistently provided and documented.
Deficiencies (3)
Failure to provide shaving care to one of three sampled residents.
Failure to ensure showers were completed for two of three sampled residents.
Failure to ensure nail care was completed for one resident.
Report Facts
Scheduled showers missed: 7
Scheduled showers missed: 5
Scheduled showers missed: 3
Shower refusals: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding expectations for hygiene care and documentation. |
| Nurse Aide A | Nurse Aide | Interviewed about shower schedules and documentation. |
| Certified Nurse Aide A | Certified Nurse Aide | Interviewed about shower schedules, documentation, and hygiene care practices. |
| Certified Nurse Aide B | Certified Nurse Aide | Interviewed about shower schedules, documentation, and hygiene care practices. |
| Administrator | Administrator | Interviewed regarding facility expectations for resident grooming and hygiene care. |
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 1
Date: May 23, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide adequate supervision and safety measures to prevent a resident from eloping from the facility.
Complaint Details
The investigation was triggered by a complaint regarding Resident #1 eloping from the facility. The resident was found outside the facility after leaving through the front door unnoticed. The facility failed to maintain proper supervision and monitoring, including 15-minute checks, and was unaware of the resident's elopement risk status until after the incident.
Findings
The facility failed to identify an elopement risk, implement safety measures, and prevent Resident #1 from eloping through the front door and exiting the building for approximately one hour. The resident was found by a neighbor and returned to the facility. The facility did not maintain proper 15-minute checks and was unaware of the resident's elopement risk status.
Deficiencies (1)
Failed to provide adequate supervision and prevent a resident from eloping from the facility.
Report Facts
Census: 50
Elopement Risk Assessments: 4
15-minute checks: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Completed Elopement Risk Assessments and was notified of the resident's elopement |
| Certified Nurse Aide A | Certified Nurse Aide (CNA) | Reported resident missing and searched for resident outside the building |
| Registered Nurse A | Registered Nurse (RN) | Placed resident on 15-minute checks and expressed concern about resident walking out |
| Administrator | Facility Administrator | Provided information about the resident's behavior and the elopement incident |
| Primary Care Physician | Primary Care Physician | Notified of the resident's elopement after the incident |
Inspection Report
Complaint Investigation
Census: 50
Deficiencies: 1
Date: Apr 12, 2024
Visit Reason
The inspection was conducted due to a complaint regarding a facility staff member making a derogatory religious statement to a resident.
Complaint Details
Complaint investigation regarding a derogatory religious statement made by staff to Resident #1. The complaint was substantiated based on interviews and observations.
Findings
The facility failed to maintain resident rights and respect when a staff member said 'happy zombie Jesus day' to a resident, which the resident reported as hurtful. The Director of Nursing acknowledged the statement was inappropriate and emphasized staff should be respectful.
Deficiencies (1)
Failure to maintain resident rights and respect when a staff member made a derogatory religious statement to a resident.
Report Facts
Residents affected: 4
Facility census: 50
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide A | Certified Nurse Aide | Named in relation to making the derogatory statement |
| Director of Nursing | Director of Nursing | Interviewed regarding the incident and staff expectations |
Inspection Report
Annual Inspection
Census: 53
Deficiencies: 18
Date: Sep 13, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care, facility environment, staffing, and other operational aspects.
Findings
The facility was found deficient in multiple areas including maintaining a safe and clean environment, developing and implementing resident-centered care plans, providing adequate assistance with activities of daily living, ensuring appropriate range of motion exercises, maintaining adequate staffing levels, ensuring proper dietary management and food preparation, maintaining sanitary kitchen conditions, safeguarding resident information, conducting quality assurance meetings with required members, and providing necessary behavioral health and dementia care services.
Deficiencies (18)
Facility failed to maintain a safe, clean, and comfortable environment with issues such as broken light covers, warped ceiling tiles, dirty vents, flies throughout the building, and peeling baseboards.
Failed to develop and implement resident-centered care plans for five sampled residents, including failure to update care plans after wounds, falls, and for contractures and Alzheimer's Disease.
Failed to provide necessary assistance with grooming, bathing, and incontinence care for six sampled residents, resulting in poor hygiene, body odor, and unclean conditions.
Failed to provide appropriate activities based on resident needs and preferences for one resident with severe cognitive impairment.
Failed to provide range of motion exercises to two residents with contractures, and lacked restorative therapy program.
Failed to ensure proper use of transfer belts and safe transfer techniques for two residents.
Failed to provide adequate nursing staff to meet resident needs, including grooming, showers, and prevention of pressure ulcers.
Failed to maintain registered nurse coverage for eight consecutive hours seven days per week.
Failed to ensure nurse aide completed required competency exam for certification within four months of hire.
Failed to provide necessary behavioral health services and professional mental health follow-up for a resident after a suicide attempt.
Dietary Manager lacked appropriate competencies and skills to manage food and nutrition services.
Failed to prepare pureed food with appropriate smooth consistency, serving thick and lumpy pureed food with particles requiring chewing.
Failed to store food and maintain kitchen in a sanitary manner, including dirty paper towel dispensers, dirty floors, unclean utensils, dusty refrigerator fan, and improper sanitizer levels.
Failed to have care plans readily accessible to pertinent staff; care plans were kept in the administrator's office and not available to nursing staff.
Failed to maintain quarterly Quality Assessment and Assurance meetings with required members including Medical Director attendance.
Failed to maintain registered nurse coverage for eight consecutive hours seven days per week as required by policy.
Failed to maintain handrails in good repair or firmly affixed to the wall in multiple areas including hallways and bathing rooms.
Failed to provide dementia care training to nurse aides and failed to provide appropriate care and interaction for a resident with dementia.
Report Facts
Deficiencies cited: 17
Census: 53
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA A | Nurse Aide | Mentioned in relation to lack of dementia care training and staffing shortages |
| CNA A | Certified Nurse Aide | Mentioned in relation to dementia care and staffing shortages |
| Director of Nursing | Director of Nursing | Provided multiple interviews regarding staffing, care plans, and facility expectations |
| Dietary Manager | Dietary Manager | Interviewed regarding lack of training and food preparation |
| Registered Dietitian | Registered Dietitian | Interviewed regarding dietary expectations and food preparation |
| Medical Director | Medical Director | Interviewed regarding attendance at QAA meetings |
| MDS Coordinator | Minimum Data Set Coordinator | Interviewed regarding care plans and infection control |
| CNA B | Certified Nurse Aide | Interviewed regarding staffing and resident care |
| CNA D | Certified Nurse Aide | Interviewed regarding wound care and ROM exercises |
| Housekeeping Aide A | Housekeeping Aide | Interviewed regarding cleaning schedules |
| Service Technician A | Service Technician | Interviewed regarding dishwasher sanitizer maintenance |
Inspection Report
Complaint Investigation
Census: 49
Deficiencies: 4
Date: Mar 28, 2023
Visit Reason
The inspection was conducted due to complaints regarding staff-to-resident abuse and medication errors involving Certified Medication Technician (CMT) A at Hill Crest Manor.
Complaint Details
The complaint involved allegations that CMT A physically abused Resident #1 by grabbing his/her arm causing bruising and verbally abused Resident #2 by calling him/her a 'needy little bitch.' The facility failed to report these allegations to the Department of Health and Senior Services and law enforcement. Investigations were incomplete and CMT A was allowed to continue working during the investigation.
Findings
The facility failed to protect residents from abuse when CMT A grabbed a resident's arm causing a bruise and verbally abused another resident. The facility also failed to report these abuse allegations to the proper authorities and did not conduct thorough investigations. Additionally, a significant medication error occurred when CMT A failed to ensure a resident swallowed a prescribed medication, apixaban.
Deficiencies (4)
Failed to keep residents free from physical and verbal abuse by staff, including grabbing a resident's arm causing bruising and calling a resident a derogatory name.
Failed to timely report suspected abuse and neglect to the Department of Health and Senior Services and law enforcement.
Failed to thoroughly investigate allegations of abuse, including inadequate interviews and allowing the accused staff to continue working.
Failed to ensure residents were free from significant medication errors when a resident missed a dose of apixaban.
Report Facts
Facility census: 49
Residents sampled: 6
Bruise size: 4.3
Bruise width: 2.1
Medication dose: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CMT A | Certified Medication Technician | Named in findings related to physical and verbal abuse and medication error. |
| DON | Director of Nursing | Responsible for investigation and oversight; failed to conduct thorough investigations and report abuse. |
| Administrator | Facility Administrator | Abuse coordinator; failed to ensure proper investigations and reporting. |
| RN A | Registered Nurse | Reported medication error and destroyed missed medication. |
| PCP A | Primary Care Physician | Commented on expectations for reporting and investigation of abuse and medication errors. |
Inspection Report
Complaint Investigation
Census: 55
Deficiencies: 5
Date: Sep 2, 2021
Visit Reason
The inspection was conducted to investigate complaints related to the facility's failure to return resident personal funds within the required timeframe, inadequate surety bond coverage for resident funds, poor maintenance and cleanliness of the facility environment, food safety violations in the kitchen, and facility safety concerns regarding pest control and door maintenance.
Complaint Details
The visit was complaint-related due to allegations of failure to return resident funds timely, inadequate surety bond, poor environmental maintenance, food safety violations, and unsafe facility conditions. The complaint was substantiated with findings of deficiencies in all these areas.
Findings
The facility was found deficient in multiple areas including failure to return resident funds within 30 days of discharge, insufficient surety bond coverage for resident funds, poor maintenance and cleanliness of resident rooms and common areas, unsafe food handling and storage practices in the kitchen, and failure to maintain an exit door free from pests and in good repair. The facility census was 55 at the time of inspection.
Deficiencies (5)
Failed to provide personal funds and a final accounting within thirty days upon discharge for ten residents.
Failed to purchase a surety bond in a sufficient amount to ensure the security of all residents' personal funds deposited with the facility.
Failed to maintain a clean and comfortable homelike environment; floors, walls, and furnishings in resident rooms and hallways were not maintained in clean condition or good repair.
Failed to prepare and serve food in accordance with professional standards; food was uncovered, flies were present in the kitchen, and improper glove use was observed.
Failed to maintain an exit door to ensure the facility stayed free from pests and rodents; door was rotted with a hole at the bottom.
Report Facts
Facility census: 55
Residents affected: 10
Surety bond amount: 43000
Required surety bond amount: 73500
Resident funds owed: 2015
Resident funds owed: 118.47
Resident funds owed: 3143.27
Resident funds owed: 3300
Resident funds owed: 288
Resident funds owed: 1168.2
Resident funds owed: 435
Resident funds owed: 1037.84
Resident funds owed: 2755
Resident funds owed: 133.61
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Business Office Manager | Interviewed regarding notification to Corporate about resident refunds and refund process | |
| Administrator | Interviewed regarding expectations for returning resident funds and facility bond coverage | |
| Maintenance Director | Interviewed regarding maintenance operations, repair reporting, and facility door condition | |
| Contracted Housekeeper A | Interviewed regarding cleaning duties and reporting repairs | |
| Contracted Housekeeper B | Interviewed regarding cleaning duties and schedules | |
| Certified Nurse Aide (CNA) A | Certified Nurse Aide | Interviewed regarding reporting repairs to Maintenance Director |
| Licensed Practical Nurse (LPN) A | Licensed Practical Nurse | Interviewed regarding reporting repairs to Maintenance Director |
| Contracted Housekeeping Supervisor | Interviewed regarding housekeeping staffing and cleaning schedules | |
| [NAME] A | Observed and interviewed regarding food handling and glove use in kitchen | |
| Dietary Manager | Interviewed regarding food safety policies and kitchen practices |
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