Inspection Reports for
Hillcrest Care Center, Inc

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.

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.

Complaint# MO00249344 is referenced related to the investigation of misappropriation by Bookkeeper A. The complaint investigation included interviews, audits, and involvement of police and Department of Health and Senior Services.

The facility failed to ensure 26 out of 27 sampled residents were free from misappropriation of their property by a bookkeeper who utilized resident trust accounts and cash for personal use totaling $20,110. The facility took disciplinary action and corrected the noncompliance by 02/10/25.

The facility failed to meet several Life Safety Code requirements including grease accumulation in kitchen hood filters, inadequate maintenance of sprinkler systems, failure to maintain smoke barriers, and improper storage of oxygen cylinders. These deficiencies had the potential to affect all occupants of the building.

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.

Complaint #MO239905 regarding the missing and injured resident was investigated and substantiated by the findings.

The facility failed to provide adequate supervision to ensure the safety of one resident, resulting in the resident being missing for several hours and sustaining injuries. The investigation revealed gaps in staff awareness and policy regarding monitoring residents on leave of absence.

Complaint #MO239905 regarding failure to supervise Resident #1, who was missing for several hours and found with injuries after a fall.

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.

The facility was found deficient in maintaining a safe, clean, and homelike environment, proper notice requirements before resident transfer or discharge, development and implementation of comprehensive care plans, adequate assistance with activities of daily living, proper labeling and storage of drugs and biologicals, and maintaining an effective pest control program.

The facility failed to maintain cooking equipment, sprinkler systems, and electrical power strips in accordance with applicable NFPA codes. Deficiencies had the potential to affect all occupants of the building.

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.

Complaint #MO00211188 regarding residents not receiving showers as scheduled was substantiated based on interviews and record reviews.

The facility failed to provide consistent resident care for activities of daily living, specifically bathing, resulting in multiple residents missing showers over extended periods. Interviews and record reviews confirmed residents did not receive showers as frequently as required or preferred.

Complaint #MO208110 & MO208111. The complaint was substantiated as the investigation confirmed sexual abuse of Resident #1 by Housekeeping Staff A.

The facility failed to protect a cognitively impaired resident from sexual abuse by a housekeeping staff member. The investigation confirmed the abuse, and the staff member was terminated immediately.

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.

The facility was found to have multiple deficiencies including failure to notify residents of survey results, failure to issue required Medicare notices, inadequate abuse/neglect policies, failure to perform employee disqualification list checks, deficiencies in drug regimen review and medication storage, and failure to provide required immunizations and education.

The facility failed to maintain adequate emergency exit illumination and exit signage, potentially affecting all residents and staff. The emergency lighting and exit signage requirements were not met as evidenced by observations and interviews.

The facility was found deficient in multiple areas including financial security, resident rights and choices, respiratory care, dialysis coordination, nurse aide in-service training, pharmacy services, food safety, and infection control. Deficiencies were documented with specific regulatory citations and corrective plans were submitted.

The facility failed to maintain emergency egress lighting, emergency lighting system testing, range hood operation, fire extinguisher signage, smoking area regulations, and proper oxygen cylinder storage. These deficiencies affected all residents, staff, and occupants in the event of a fire or emergency.

The facility was found to have multiple deficiencies including failure to promote resident self-determination, inadequate notification before transfers or discharges, incomplete implementation of comprehensive care plans, improper medication administration practices, and lapses in infection control protocols. Several residents were affected by these deficiencies.

The facility failed to meet several provisions of the 2012 Life Safety Code including issues with egress doors, sprinkler system installation and maintenance, smoke barriers, smoking regulations, and oxygen storage. Multiple deficiencies were identified affecting resident safety in the event of a fire.