Inspection Reports for
Hill Crest Manor
801 SOUTH COLBY, HAMILTON, MO, 64644-8287
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
18 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
227% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
47% occupied
Based on a June 2025 inspection.
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
Annual Inspection
Census: 56
Deficiencies: 2
Date: Oct 29, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations regarding care provided to dependent residents, specifically focusing on activities of daily living such as hygiene and grooming.
Findings
The facility failed to ensure dependent residents received necessary personal hygiene services, including shaving, showers, and nail care. Deficiencies were documented related to incomplete care plans and inconsistent provision and documentation of hygiene services.
Deficiencies (2)
F677: The facility did not provide necessary ADL care for dependent residents, including failure to provide shaving care, complete showers, and nail care for sampled residents. Care plans lacked documentation for activities of daily living, bathing, and shaving preferences.
A4077: Residents were not consistently groomed or dressed appropriately for the time of day, environment, and medical conditions. This deficiency references F677 and is classified as Class II.
Report Facts
Facility census: 56
Scheduled showers in last 30 days: 11
Showers received in last 30 days: 4
Scheduled showers in last 30 days: 8
Showers received in last 30 days: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA A | Nurse Aide | Interviewed regarding shower schedules and care |
| CNA A | Certified Nurse Aide | Interviewed regarding shower schedules and care |
| CNA B | Certified Nurse Aide | Interviewed regarding shower schedules and care |
| Director of Nursing | Interviewed regarding care expectations and staff instructions | |
| Administrator | Interviewed regarding grooming and hygiene expectations |
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
Follow-Up
Census: 50
Deficiencies: 2
Date: May 23, 2024
Visit Reason
The visit was conducted as a follow-up to verify correction of previous deficiencies related to resident elopement risk and supervision.
Findings
The facility failed to provide adequate supervision and safety measures to prevent a resident from eloping. The resident was found outside the facility unsupervised, indicating a lapse in monitoring and safety protocols.
Deficiencies (2)
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to provide adequate supervision and safety measures to prevent a resident from eloping, as evidenced by the resident leaving the facility unsupervised and wandering outside for approximately one hour.
A4075 Nursing Care per Resident Condition: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met as evidenced by the deficiency in F689.
Report Facts
Facility census: 50
Completion date for plan of correction: Jun 14, 2024
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
Complaint Investigation
Census: 50
Deficiencies: 2
Date: Apr 12, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding a derogatory religious statement made by a staff member to a resident.
Complaint Details
The complaint was substantiated based on interviews with Resident #1, a Certified Nurse Aide, and the Director of Nursing, confirming a staff member made a derogatory statement referencing 'happy zombie Jesus day' which offended the resident.
Findings
The facility failed to maintain resident rights and respect when a staff member made a derogatory religious statement to a resident. The facility policies on resident dignity and respect were reviewed, and interviews confirmed the incident.
Deficiencies (2)
F550 Resident Rights. The facility failed to maintain resident rights and respect when a staff member made a derogatory religious statement to a resident, causing emotional distress.
A8030 Dignity/Privacy. The facility did not ensure residents were treated with full recognition of dignity and privacy, as evidenced by the derogatory statement incident.
Report Facts
Facility census: 50
Brief Interview of Mental Status (BIMS): 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marlene Klepees | RN Director of Nursing | Re-educated CNA regarding resident dignity and communication as part of plan of correction |
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: 3
Deficiencies: 2
Date: Sep 13, 2023
Visit Reason
The inspection was conducted as a complaint investigation regarding facility conditions and pest control at Hill Crest Manor.
Complaint Details
The visit was complaint-related, investigating allegations of poor carpet maintenance and pest infestation. The findings substantiated the complaints with observations and interviews confirming issues.
Findings
The facility failed to maintain carpet cleanliness and failed to implement effective pest control measures to minimize bed bugs. Observations and interviews confirmed dirty carpets and presence of bed bugs affecting residents.
Deficiencies (2)
19 CSR 30-87.020(13) Carpeting: The facility failed to ensure all carpet was maintained in good repair, with dark brown dirt spots observed in hallways and resident rooms. The census was 3.
19 CSR 30-87.020(39) Inspect/Rodent Control: The facility failed to implement effective measures to minimize pests, including bed bugs, with evidence of bugs found on a resident's recliner and reports from the resident. The census was 3.
Report Facts
Census: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding carpet condition and pest control; acknowledged carpet needed cleaning and was responsible for pest control oversight. |
Inspection Report
Life Safety
Census: 53
Capacity: 90
Deficiencies: 14
Date: Sep 11, 2023
Visit Reason
An Emergency Preparedness portion of a Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid emergency preparedness requirements and life safety codes.
Findings
The facility failed to meet several life safety code requirements including emergency preparedness policies, building construction standards, means of egress, self-closing doors, illumination of means of egress, exit signage, fire alarm testing and maintenance, sprinkler system maintenance, and fire extinguisher maintenance. The facility had a capacity of 90 beds and a census of 53 residents at the time of survey.
Deficiencies (14)
E015 Subsistence Needs for Staff and Patients. The facility failed to include the method of evacuation during a climate event in its emergency preparedness plan. The facility census was 53 residents.
K161 Building Construction Type and Height. The facility failed to maintain the Type V (111) protected wood-frame construction standard, with holes and penetrations in ceilings. The facility had a capacity of 90 and a census of 53.
K211 Means of Egress - General. The facility failed to maintain all exits and exit corridors free of obstructions, affecting one of five resident wings with 90 beds and 53 residents.
K223 Doors with Self-Closing Devices. The facility failed to ensure doors to hazardous areas had self-closing devices and no impediments to closing. The census was 53 with a licensed capacity of 90.
K281 Illumination of Means of Egress. The facility failed to provide emergency lighting in all exit areas. The facility had a capacity of 90 and a census of 53 residents.
K293 Exit Signage. The facility failed to maintain exit signage for evacuation in one of four smoke zones and all occupants of the enclosed courtyard. The census was 53 with a capacity of 90.
K321 Hazardous Areas - Enclosure. The facility failed to maintain hazardous areas separated by fire barriers and self-closing doors. The census was 53 with a licensed capacity of 90.
K324 Cooking Facilities. The facility failed to maintain UL 300 range hood according to NFPA 17A standards, affecting occupants in one of five smoke zones. Capacity was 90 and census 53.
K345 Fire Alarm System - Testing and Maintenance. The facility failed to ensure authorized personnel could access, silence, and reset the fire alarm panel and failed to complete a smoke sensitivity test. Capacity was 90 and census 53.
K353 Sprinkler System - Maintenance and Testing. The facility failed to maintain sprinkler system monitoring and failed to monitor water supply integrity. The facility had a capacity of 90 with a census of 53.
K355 Portable Fire Extinguishers. The facility failed to maintain portable fire extinguishers in two of 12 smoke compartments. The facility had a capacity of 90 and a census of 53 residents.
K363 Corridor - Doors. The facility failed to maintain corridor doors to resist smoke passage and latch when closed. The facility had a capacity of 90 with a census of 53.
K541 Rubbish Chutes, Incinerators, and Laundry Chutes. The facility failed to ensure vertical openings were enclosed and sealed by fire-resistive construction. The facility had a capacity of 90 and a census of 53.
K920 Electrical Equipment - Power Cords and Extension Cords. The facility failed to ensure proper use and maintenance of power strips and extension cords in patient care areas. The facility had a capacity of 90 with a census of 53.
Report Facts
Facility census: 53
Total licensed capacity: 90
Number of sprinkler heads recalled: 125
Inspection Report
Plan of Correction
Census: 3
Deficiencies: 7
Date: Aug 8, 2023
Visit Reason
The document is a plan of correction related to deficiencies identified during a state survey conducted on 08/08/2023 at Hill Crest Manor.
Findings
The facility failed to meet several fire safety and building maintenance regulations, including lack of annual local fire department consultation, locked resident room doors without proper emergency access, storage of excessive combustible materials, malfunctioning smoke section partitions, improper disposal of ashtray contents, and poor building maintenance such as damaged drywall and electrical issues. These deficiencies affected three residents.
Deficiencies (7)
19 CSR 30-86.022(5)(A) Fire Drill/Evacuation Plan, Consultation. Facility failed to complete an annual local fire department consultation as required. Records review found no consultation documentation.
19 CSR 30-86.022(7)(F) Locked Resident Room Doors. Facility failed to ensure staff have means to open locked resident room doors in emergencies. Staff lacked keys and used credit cards as work-around.
19 CSR 30-86.022(10)(B) Combustible Materials, Unnecessary Storage Of. Facility failed to prevent storage of excessive combustible materials in rooms not rated or sprinklered, creating hazards and disarray.
19 CSR 30-86.022(10)(I) Smoke Section Partitions > than 20 beds. Facility failed to ensure smoke separation doors close and function properly; door was stuck and missing seal, creating a gap.
19 CSR 30-86.022(14)(C) Ashtray Contents Properly Disposed. Facility failed to properly dispose of smoking materials; cigarette butts and trash were mixed and scattered in multiple locations.
19 CSR 30-86.032(2) Substantially Constructed & Maintained. Facility failed to maintain building in good repair; drywall bowed and hole in fire wall noted.
19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected. Facility failed to maintain electrical system safely; missing outlet plates and exposed wiring observed in multiple rooms.
Report Facts
Facility census: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Interviewed regarding fire drill consultation, lock issues, combustible storage, smoke door, ashtray disposal, building maintenance, and electrical issues | |
| Maintenance Director | Interviewed regarding lost keys and building maintenance issues |
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: 47
Capacity: 75
Deficiencies: 6
Date: Jan 31, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to notify the physician of a resident's significant change in condition and allegations of abuse, neglect, and misappropriation of resident property.
Complaint Details
The complaint investigation was substantiated. The facility was found to have failed in timely physician notification of a significant change in condition, failed to keep residents free from abuse and neglect, and failed to properly investigate and report abuse allegations.
Findings
The facility failed to notify the physician timely about a resident's significant change in condition involving marijuana ingestion and oxygen saturation issues. The facility also failed to keep two residents free from abuse and neglect, including misappropriation of resident property by staff. Multiple medication errors and inadequate investigations were noted.
Deficiencies (6)
F580: The facility failed to notify the physician promptly of a resident's significant change in condition involving marijuana ingestion and decreased oxygen saturation.
F600: The facility failed to keep two residents free from abuse and neglect, including failure to protect from physical abuse and misappropriation of resident property by staff.
F609: The facility failed to investigate and report allegations of abuse, neglect, and exploitation to the appropriate authorities in a timely manner.
F610: The facility failed to thoroughly investigate allegations of abuse and neglect and failed to take appropriate corrective actions.
F658: The facility failed to meet professional standards for medication administration and failed to develop and implement policies to prevent medication errors.
F760: The facility failed to ensure residents were free of significant medication errors, including failure to prevent a resident from swallowing a medication not prescribed for them.
Report Facts
Facility census: 47
Total capacity: 75
Number of residents sampled: 6
Number of residents involved in medication error review: 40
Inspection Report
Plan of Correction
Census: 3
Deficiencies: 1
Date: Jan 31, 2023
Visit Reason
The inspection was conducted due to a regulatory oversight regarding the operator/administrator responsibilities and compliance with licensure regulations related to staff residing in state licensed rooms.
Findings
The facility failed to comply with state regulations by allowing two staff members and their child to reside in rooms licensed for residents without notifying the State Survey Agency. The administrator did not provide a policy on room utilization and was aware staff were living in resident rooms without proper licensure status changes.
Deficiencies (1)
19 CSR 30-86.042(4) Operator/Administrator Responsibilities. The facility allowed two staff members and their child to reside in resident-licensed rooms without contacting the State Survey Agency to change room status. The facility census was 3.
Report Facts
Facility census: 3
Inspection Report
Life Safety
Census: 4
Deficiencies: 6
Date: Jul 22, 2022
Visit Reason
The inspection was a fire safety inspection conducted on July 22, 2022, to assess compliance with fire safety regulations and building maintenance standards at Hill Crest Manor.
Findings
The facility failed to allow access to inspect a portion of the building, had locked resident room doors with hasps and padlocks, failed to maintain smoke partitions and fire-rated doors, and had multiple maintenance and electrical deficiencies affecting all four residents present.
Deficiencies (6)
19 CSR 30-86.022(2)(D) Inspection Rights, No Fire Hazard. The facility failed to allow access to inspect a portion of the building not separated by two-hour fire-resistant construction. This affected four residents.
19 CSR 30-86.022(7)(F) Locked Resident Room Doors. The facility installed hasps on resident room doors for padlocks, which is not permitted. This deficiency potentially affects four residents.
19 CSR 30-86.022(10)(I) Smoke Section Partitions > than 20 beds. The facility failed to maintain one-hour fire-rated smoke partitions and fire doors, allowing gaps and missing hardware. This affects four residents.
19 CSR 30-86.032(2) Substantially Constructed & Maintained. The building is not maintained in good repair, with missing panic bar hardware and holes in exit doors. This affects four residents.
19 CSR 30-86.032(13) Electrical Wiring, Maintained, Inspected. The facility failed to maintain electrical wiring and equipment in accordance with the National Electrical Code. This affects four residents.
19 CSR 30-86.032(23) Rooms Neat, Orderly, Cleaned Daily. The facility failed to ensure rooms were neat, orderly, and cleaned daily, with strong odors and clutter in resident rooms. This affects four residents.
Report Facts
Facility census: 4
Inspection Report
Routine
Census: 58
Deficiencies: 5
Date: Jun 29, 2022
Visit Reason
The inspection was a routine survey to assess compliance with health and safety regulations at Hill Crest Manor.
Findings
The facility failed to maintain a safe, functional, sanitary, and comfortable environment due to standing water in the basement and ineffective pest control with flies present in resident areas. Additionally, the facility did not ensure registered nurse coverage on the day shift as required.
Deficiencies (5)
F921: The facility failed to maintain non-resident use areas in good, safe, sanitary conditions as standing water was observed in the basement. The facility census was 58.
F925: The facility failed to maintain an effective pest control program as flies were observed landing on residents and their food, affecting three sampled residents. The facility census was 58.
A3001: The building was not substantially constructed and maintained in good repair, as referenced in F921. The deficiency was classified as Class II.
A4040: The facility failed to ensure a registered nurse was on duty during the day shift, with staffing records showing multiple days without RN coverage. The facility census was 58.
A6039: The facility failed to implement effective measures to minimize rodents, flies, cockroaches, and other insects, as referenced in F925. The deficiency was classified as Class II.
Report Facts
Facility census: 58
Deficiencies cited: 5
Inspection Report
Routine
Deficiencies: 0
Date: Feb 3, 2022
Visit Reason
A COVID-19 focused emergency preparedness survey was conducted to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
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 |
Inspection Report
Annual Inspection
Census: 55
Deficiencies: 5
Date: Sep 2, 2021
Visit Reason
Annual inspection survey conducted to assess compliance with federal and state regulations for Hill Crest Manor nursing facility.
Findings
The facility was found deficient in several areas including failure to provide timely notice and conveyance of personal funds, insufficient surety bond coverage, and failure to maintain a safe, clean, and homelike environment. Food safety and environmental conditions were also cited for noncompliance.
Deficiencies (5)
F569 Notice and Conveyance of Personal Funds: The facility failed to provide personal funds and a final accounting within thirty days upon discharge for ten residents. Facility census was 55.
F570 Surety Bond-Security of Personal Funds: The facility failed to purchase a surety bond in a sufficient amount to ensure the security of all residents' personal funds. Facility census was 55.
F584 Safe/Clean/Comfortable/Homelike Environment: The facility failed to maintain a clean and comfortable homelike environment, including issues with cleanliness, maintenance, and pest control. Facility census was 55.
F812 Food Procurement, Store, Prepare, Serve-Sanitary: The facility failed to prepare and serve food in accordance with professional food service safety standards. Facility census was 55.
F921 Safe/Functional/Sanitary/Comfortable Environment: The facility failed to maintain one exit door to prevent pest and rodent entry. Facility census was 55.
Report Facts
Facility census: 55
Residents affected: 10
Surety bond amount: 43000
Required surety bond amount: 73500
Increased surety bond amount: 75000
Inspection Report
Life Safety
Census: 55
Capacity: 90
Deficiencies: 6
Date: Sep 2, 2021
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association and related regulations.
Findings
The facility failed to maintain the two-hour fire rated wall between multiple occupancies, did not install a manual fire alarm pull station at a required exit, had sprinkler heads loaded with dust, failed to maintain smoke barrier walls, and did not provide ground fault circuit interrupters in some resident rooms. Additionally, smoking regulations signage and ashtray provisions were not properly maintained.
Deficiencies (6)
K133 Multiple Occupancies - Construction Type: The facility failed to maintain the two-hour fire rated wall between multiple occupancies, exposing framing material and gaps in the fire wall.
K342 Fire Alarm System - Initiation: The facility failed to install a manual fire alarm pull station at an exit door labeled as therapy, making it inaccessible in an emergency.
K353 Sprinkler System - Maintenance and Testing: Sprinkler heads in multiple rooms were loaded with dust, potentially affecting performance.
K372 Subdivision of Building Spaces - Smoke Barrier Construction: The facility failed to maintain smoke barrier walls, with gaps exposing wood framing material.
K511 Utilities - Gas and Electric: The facility failed to provide Ground Fault Circuit Interrupters (GFCI) in resident rooms within six feet of sinks, affecting three smoke compartments.
K741 Smoking Regulations: The facility failed to provide proper signage outside resident doors where oxygen tanks were in use and did not provide metal containers with self-closing lids for cigarette butts in designated smoking areas.
Report Facts
Facility capacity: 90
Resident census: 55
Deficiencies cited: 6
Inspection Report
Plan of Correction
Census: 4
Deficiencies: 4
Date: Sep 1, 2021
Visit Reason
The inspection was conducted to identify deficiencies in medication administration, facility maintenance, food safety, and resident fund bond requirements at Hill Crest Manor.
Findings
The facility failed to ensure a safe and effective medication system, maintain bathroom walls and ceilings in good repair, prepare and serve food according to professional standards, and maintain a sufficient surety bond for residents' personal funds.
Deficiencies (4)
19 CSR 30-86.042(51) Safe/Effective Medication System: The facility failed to develop and implement a safe medication system, as staff did not observe residents taking medications and left medications unattended.
19 CSR 30-87.020(15) Walls/Ceilings/Doors/Windows Clean: The facility failed to maintain bathroom walls and ceilings in good repair, with mold spots observed in Resident #2's bathroom.
19 CSR 30-87.030(13) Food-Protected, Temp, Need to Contact DHSS: The facility failed to prepare and serve food in accordance with professional standards, including uncovered food and flies in the kitchen.
19 CSR 30-88.020(14) Resident Fund Bond Requirements: The facility failed to purchase a surety bond in a sufficient amount to secure residents' personal funds.
Report Facts
Facility census: 4
Bond amount 2020: 43000
Required bond amount: 73500
Bond increase amount: 75000
Inspection Report
Routine
Deficiencies: 0
Date: Dec 9, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey were conducted from November 23 to December 9, 2020.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness.
Inspection Report
Routine
Deficiencies: 0
Date: Nov 4, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted from November 2 to November 4, 2020 to assess compliance with relevant regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Routine
Deficiencies: 0
Date: Oct 20, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey were conducted to assess compliance with CDC and CMS guidelines and federal regulations.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: May 28, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey and a COVID-19 Focused Emergency Preparedness survey were conducted on May 27 and May 28, 2020 to assess compliance with CMS and CDC recommended practices and federal emergency preparedness regulations.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices for COVID-19 infection control and with 42 CFR 483.73 related to emergency preparedness.
Inspection Report
Annual Inspection
Census: 55
Deficiencies: 14
Date: Jul 24, 2019
Visit Reason
The inspection was an annual survey conducted to assess compliance with Medicare and Medicaid regulations at Hill Crest Manor.
Findings
The facility was found deficient in multiple areas including failure to issue required notices to residents, maintaining a safe and clean environment, meeting professional standards in medication administration, providing adequate activities, and ensuring proper food safety and sanitation. The facility had a census of 55 at the time of the survey.
Deficiencies (14)
F582: The facility failed to issue the Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) to residents when they were no longer eligible for skilled nursing services.
F584: The facility failed to maintain a safe, clean, comfortable, and homelike environment, with multiple examples of unclean areas and poor housekeeping.
F658: The facility failed to meet professional standards in medication administration, including failure to follow the '5 rights' and document insulin administration properly.
F679: The facility failed to provide an ongoing program of activities designed to meet the interests and needs of residents, with low participation and inadequate documentation.
F812: The facility failed to properly sanitize dishes and maintain dishwasher temperatures, affecting food safety.
F908: The facility failed to maintain mechanical equipment in safe operating condition, including a stove and oven with grease buildup and malfunctioning parts.
A1013: The facility failed to provide adequate cooking and baking areas, with violations related to cleanliness and maintenance.
A3039: The facility failed to maintain rooms neat, orderly, and cleaned daily.
A4074: The facility failed to provide personal attention and consistent nursing care per resident condition.
A4100: The facility failed to provide an adequate activity program with individualized and group activities appropriate to residents' needs.
A6008: The facility failed to provide sufficient ventilation to keep rooms free of excessive heat, steam, odors, and fumes.
A7054: The facility failed to properly clean and sanitize equipment and surfaces intended for food contact.
A7056: The facility failed to maintain hot water sanitizing temperatures at or above 170 degrees Fahrenheit.
A7075: The facility failed to maintain water temperature and thermometer accuracy for sanitizing equipment.
Report Facts
Facility census: 55
Sampled residents: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Smith | Director of Nursing | Named in medication administration deficiency and plan of correction. |
| Dietary Staff A | Dietary Staff | Mentioned in relation to dishwasher temperature and food safety deficiencies. |
| Dietary Manager | Dietary Manager | Mentioned regarding dishwasher chemical logs and temperature monitoring. |
| Administrator | Administrator | Interviewed regarding housekeeping and activity program deficiencies. |
Inspection Report
Life Safety
Census: 55
Capacity: 90
Deficiencies: 4
Date: Jul 24, 2019
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code and related fire safety regulations for Hill Crest Manor.
Findings
The facility failed to maintain required fire safety measures including a hole in a smoke barrier wall, doors with self-closing devices that did not close properly, and incomplete quarterly sprinkler inspections. These deficiencies affected multiple smoke compartments and residents.
Deficiencies (4)
K131: The facility failed to maintain the minimum two-hour separation between health care occupancies due to a 1.5 inch diameter hole containing internet cables in the smoke barrier wall.
K223: The facility failed to protect a hazardous room with a working self-closing device when the smoke room corridor door did not completely close, leaving a 0.5 inch gap.
K353: The facility failed to have timely quarterly inspections of the sprinkler system, potentially affecting all residents.
K363: Corridor doors were held open improperly, contained holes, or failed to close, affecting two smoke compartments and 29 residents.
Report Facts
Facility capacity: 90
Resident census: 55
Residents affected: 29
Inspection Report
Plan of Correction
Census: 54
Deficiencies: 3
Date: Aug 23, 2018
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding resident assessments and infection prevention and control at Hill Crest Manor.
Findings
The facility failed to complete and transmit Minimum Data Set (MDS) discharge assessments within seven days for three sampled residents. Additionally, the facility failed to ensure staff practiced proper infection control measures, including hand hygiene and glove use, affecting three residents.
Deficiencies (3)
F640: The facility failed to complete and transmit MDS discharge assessments within seven days after discharge for three sampled residents. No documentation indicated staff completed the MDS discharge assessment timely.
F880: The facility failed to assure staff practiced infection control measures, including hand washing and changing gloves during perineal care and transfers, affecting three of 14 sampled residents.
A4085: The facility did not meet infection control requirements related to reporting communicable diseases to the state within seven days as required.
Report Facts
Facility census: 54
Residents sampled for MDS discharge assessment: 3
Sampled residents affected by infection control deficiencies: 3
Sampled residents reviewed for infection control: 14
Inspection Report
Life Safety
Census: 54
Capacity: 90
Deficiencies: 2
Date: Aug 23, 2018
Visit Reason
The inspection was conducted to assess compliance with the life safety code of the National Fire Protection Association, specifically focusing on fire drills and emergency preparedness.
Findings
The facility failed to meet the requirements for conducting fire drills as per NFPA 101, 2012 edition. Fire drills were not conducted at unexpected times under varying conditions as required, potentially affecting all residents.
Deficiencies (2)
K712 Fire Drills: The facility failed to conduct fire drills at unexpected times under varying conditions as required by NFPA 101, 2012 edition. Fire drills were scheduled too closely together and did not familiarize occupants with routine emergency responses.
A2061 Fire Drill Requirements, Evacuation: The facility did not conduct the minimum required twelve fire drills annually with at least one every three months, including unannounced drills to residents and staff. The regulation was not met as evidenced by the deficiency in K712.
Report Facts
Facility capacity: 90
Facility census: 54
Number of fire drills required annually: 12
Number of fire drills required quarterly: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Mary Perry | Administrator | Signed the plan of correction and approval of findings |
Inspection Report
Plan of Correction
Census: 9
Deficiencies: 3
Date: Aug 23, 2018
Visit Reason
The inspection was conducted to identify deficiencies in facility maintenance, staff identification badge compliance, and resident record keeping, followed by submission of a plan of correction.
Findings
The facility was found to have multiple deficiencies including poor maintenance of carpets and caulking, staff not wearing identification badges, and failure to maintain monthly summaries of residents' general condition and needs.
Deficiencies (3)
19 CSR 30-86.032(2) Substantially Constructed & Maintained: The facility failed to keep residents' carpets and caulking around toilets in good condition, with multiple rooms showing stains and loose caulking.
19 CSR 30-86.042(14) Identification Badge Requirements: Staff who have contact with residents did not wear identification badges during duty or service delivery.
19 CSR 30-86.042(62)(B) Resident Record Requirements: The facility failed to maintain monthly statements of residents' general condition and needs for three sampled residents.
Report Facts
Facility census: 9
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