Inspection Reports for
Hillcrest Care Center, Inc
1108 CLARKE ST, DE SOTO, MO, 63020-2706
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
5.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
Same as Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Occupancy
Latest occupancy rate
70% occupied
Based on a March 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 1
Date: Mar 28, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding misappropriation of resident property by a bookkeeper who used resident trust accounts and cash for personal use.
Complaint Details
Complaint #MO00249344 involved allegations of misappropriation of resident property by Bookkeeper A. The complaint was substantiated with evidence of misuse of resident trust accounts and cash. The bookkeeper was terminated and law enforcement was involved, but the bookkeeper has not cooperated with the investigation.
Findings
The facility failed to protect residents from misappropriation of their property, with 26 out of 27 sampled residents affected by wrongful use of their trust accounts and cash totaling $20,110. The facility took disciplinary action against the bookkeeper, refunded residents, and implemented staff in-service on policies.
Deficiencies (1)
Failure to protect residents from wrongful use of their belongings or money by Bookkeeper A, involving misappropriation of resident trust accounts and cash totaling $20,110.
Report Facts
Residents affected: 26
Facility census: 84
Amount misappropriated: 20110
Number of resident RTAs affected: 5
Cash withdrawals for Resident #1: 1346
Cash withdrawals for Resident #2: 1254
Cash withdrawals for Resident #3: 899
Cash withdrawals for Resident #4: 1436
Cash withdrawals for Resident #5: 430
Cash withdrawals for Resident #6: 420
Unaccounted funds for Resident #9: 12885
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Bookkeeper A | Bookkeeper | Named in misappropriation of resident funds and termination |
| SSA B | Social Services Assistant | Notified family of low resident trust account funds and informed administrator |
| Administrator | Facility Administrator | Initiated investigation, notified authorities, and described policy on cash disbursement |
| FA | Stated Bookkeeper A received appropriate training on resident trust accounts |
Inspection Report
Annual Inspection
Census: 80
Deficiencies: 6
Date: Oct 24, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care, environment, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to maintain a safe, clean, and homelike environment; failure to provide timely notification of resident transfers and bed hold policies; inadequate documentation and care related to pressure ulcers; failure to provide appropriate dialysis communication and care; and insufficient nurse aide in-service education, particularly in dementia care.
Deficiencies (6)
Failed to provide a safe, clean and comfortable homelike environment with issues such as cigarette debris, insect droppings, peeled paint, holes in walls, and cluttered laundry room.
Failed to notify residents and/or representatives in writing of hospital transfers and reasons for transfer for four residents.
Failed to notify residents and/or representatives in writing of bed hold policy at time of hospital transfer for four residents.
Failed to document type, stage, measurements, and characteristics of pressure ulcers for two residents.
Failed to provide documentation of communication between facility and dialysis center for three residents, with multiple missed dialysis communication forms.
Failed to conduct at least twelve hours of nurse aide in-service education per year and failed to provide required annual competencies in dementia care for two nurse aides.
Report Facts
Facility census: 80
Missed dialysis communication forms: 13
Missed dialysis communication forms: 14
Missed dialysis communication forms: 12
Missed dialysis communication forms: 10
Missed dialysis communication forms: 14
Missed dialysis communication forms: 12
Missed dialysis communication forms: 13
Missed dialysis communication forms: 9
Missed dialysis communication forms: 13
Missed dialysis communication forms: 14
Missed dialysis communication forms: 12
Missed dialysis communication forms: 8
Nurse aide in-service hours: 9.5
Nurse aide in-service hours: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeper A | Mentioned in relation to environmental issues and cleaning responsibilities | |
| Kitchen Employee B | Mentioned in relation to reporting maintenance issues | |
| Administrator | Provided expectations on environmental concerns, transfer/discharge forms, and nurse aide education | |
| Maintenance Supervisor | Responsible for maintenance log and cleaning designated smoking area | |
| Housekeeper E | Mentioned regarding floor technician duties and laundry coverage | |
| Assistant Director of Nursing | ADON | Interviewed about transfer/discharge forms, bed hold policy, skin assessments, dialysis communication, and nurse aide education |
| Social Service Designee | SSD | Responsible for keeping transfer/discharge and bed hold policy forms; admitted to lack of follow-up |
| Certified Nurse Assistant G | CNA | Reported first time seeing resident's skin injury |
| Certified Nurse Assistant I | CNA | Reported first time seeing resident's skin injury |
| Licensed Practical Nurse F | LPN | Interviewed about resident skin treatment and dialysis communication |
| Director of Nursing | DON | Interviewed about skin assessments and dialysis communication |
| Certified Medication Technician J | CMT | Interviewed about resident heel protectors |
| Certified Nurse Aide C | CNA | Nurse aide with insufficient in-service hours and missing dementia care competency |
| Certified Nurse Aide D | CNA | Nurse aide with insufficient in-service hours and missing dementia care competency |
Inspection Report
Complaint Investigation
Census: 84
Deficiencies: 1
Date: Aug 1, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide adequate supervision to ensure the safety of a resident who was missing and found outside after a fall.
Complaint Details
Complaint #MO239905 regarding failure to supervise Resident #1, who was missing for several hours and found with injuries after a fall.
Findings
The facility failed to initiate a timely search for Resident #1 after staff noticed the resident's call light on but the room was empty. The resident was found outside in the courtyard after lying there for approximately eleven hours following a fall, resulting in multiple abrasions. The facility was notified of immediate jeopardy which was corrected on the same day.
Deficiencies (1)
Failure to provide adequate supervision to ensure resident safety, resulting in a resident being missing and found outside after a fall.
Report Facts
Census: 84
Duration resident missing: 11
Abrasions size: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Technician C | Certified Medication Technician (CMT) | Reported resident missing and informed Director of Nursing |
| Director of Nursing | Director of Nursing (DON) | Last saw resident at 11:30 P.M., did not initiate search when resident was missing |
| Licensed Practical Nurse D | Licensed Practical Nurse (LPN) | Notified after resident was found outside and assessed injuries |
| LPN B | Licensed Practical Nurse (LPN) | Last saw resident between 11:30-11:45 P.M. |
| Medical Records staff | Found resident laying outside and notified nurse and LPN D | |
| Administrator | Administrator | Interviewed regarding facility policies and investigation |
Inspection Report
Routine
Census: 75
Deficiencies: 7
Date: Aug 25, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, environment safety, medication management, immunizations, pest control, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to maintain a safe and homelike environment, inadequate notification of resident transfers and bed hold policies, incomplete care plans, insufficient assistance with activities of daily living such as showering, improper medication storage and documentation, lack of immunization documentation and education, and ineffective pest control program.
Deficiencies (7)
Failed to provide a safe, clean, and comfortable homelike environment with missing corner bead, soiled privacy curtains, and unsecured cove base.
Failed to notify residents and/or representatives in writing of hospital transfers and bed hold policies for three residents.
Failed to implement complete care plans with specific interventions for dementia, oxygen use, and chronic kidney disease for two residents.
Failed to provide residents with a minimum of two showers per week for six residents, with inadequate documentation of shower refusals.
Failed to label and store medications properly, including unlocked controlled substances, expired medications, and lack of temperature logs for medication refrigerator.
Failed to provide and document influenza and pneumococcal vaccinations or education for two residents.
Failed to maintain an effective pest control program resulting in flies observed on and around multiple residents and in common areas.
Report Facts
Residents sampled: 18
Facility census: 75
Shower opportunities missed: 21
Shower opportunities missed: 18
Shower opportunities missed: 15
Shower opportunities missed: 15
Shower opportunities missed: 10
Shower opportunities missed: 5
Medication count discrepancy: 1
Novolog insulin pen usage: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Mentioned in relation to maintenance log and pest control issues |
| RN H | Registered Nurse | Mentioned in relation to maintenance log and pest control issues |
| Social Services Designee (SSD) | Mentioned in relation to transfer/discharge notification deficiencies | |
| Administrator | Mentioned in relation to expectations for maintenance, transfer notifications, bed hold notices, pest control | |
| Maintenance Supervisor | Mentioned in relation to maintenance and pest control log management | |
| Registered Nurse D | Registered Nurse | Mentioned in relation to care plan and fluid restriction knowledge |
| Director of Nursing (DON) | Mentioned in relation to medication storage and disposal | |
| Assistant Director of Nursing (ADON) | Mentioned in relation to medication storage, immunizations, shower documentation | |
| Certified Medication Technician (CMT) E | Mentioned in relation to medication signing out discrepancies | |
| Licensed Practical Nurse (LPN) F | Mentioned in relation to shower frequency and documentation | |
| Certified Nursing Assistant (CNA) G | Mentioned in relation to shower frequency and documentation | |
| Certified Nursing Assistant (CNA) B | Mentioned in relation to pest control observations | |
| CNA C | Mentioned in relation to pest control observations |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Jun 21, 2023
Visit Reason
Annual inspection survey completed on 06/21/2023 for regulatory compliance of Hillcrest Care Center Inc.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Census: 76
Deficiencies: 7
Date: Apr 16, 2021
Visit Reason
Routine inspection to assess compliance with federal regulations including resident rights, medication management, employee background checks, and vaccination policies.
Findings
The facility was found deficient in multiple areas including failure to notify residents of survey results availability, failure to issue required Medicare notices, failure to perform periodic employee disqualification list checks, failure to ensure physician review of pharmacist medication recommendations, medication storage errors with refrigerator temperatures below freezing affecting insulin storage, improper labeling and storage of medications, and failure to provide pneumococcal vaccine education and offer vaccines to residents.
Deficiencies (7)
Failed to notify residents of the availability and location of the most recent survey results in an accessible location.
Failed to issue CMS Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) Form 10055 for one resident.
Failed to perform periodic checks of the Employee Disqualification List for nine out of ten sampled employees.
Failed to ensure attending physician reviewed Consultant Pharmacist's Gradual Dose Reduction recommendations and document actions taken for one resident.
Medication refrigerator temperatures were below freezing for multiple days, potentially affecting chemical properties of stored medications for multiple residents.
Failed to store drugs and biologicals in accordance with professional standards, including locked compartments and proper labeling.
Failed to provide information, education, and offer both pneumococcal vaccines to two residents upon admission.
Report Facts
Residents affected: 2
Residents affected: 1
Employees affected: 9
Residents affected: 1
Residents affected: 9
Residents affected: 2
Facility census: 76
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Mentioned in relation to failure to notify residents of survey results and failure to issue CMS SNF ABN Form 10055 | |
| Administrator | Mentioned in relation to survey results accessibility, CMS SNF ABN Form 10055 understanding, and medication storage expectations | |
| Director of Nursing (DON) | Mentioned in relation to physician medication review and medication refrigerator temperature issues | |
| Assistant Director of Nursing (ADON) | Mentioned in relation to pneumococcal vaccine offering |
Viewing
Loading inspection reports...
