Inspection Reports for Hillcrest Family Services – RCF
1160 Seippel Road, Dubuque, IA, 520029647
Back to Facility ProfileInspection Report Summary
The most recent inspection on April 24, 2025, found no deficiencies during the investigation of multiple incidents and complaints. Earlier inspections showed a pattern of deficiencies primarily related to supervision and staffing, service plan updates, and dietary planning. Some investigations substantiated issues such as failure to provide adequate supervision for residents at risk of elopement or self-harm, incomplete service plan modifications, and nutritional menu deficiencies. There were no fines, immediate jeopardy findings, or license actions listed in the available reports, and most complaint investigations were unsubstantiated. The facility’s record shows some improvement over time, with no deficiencies noted in the most recent inspections following prior citations.
Deficiencies (last 7 years)
Deficiencies (over 7 years)
4.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
7% better than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Apr 24, 2025
Visit Reason
Investigation of multiple incidents and complaints including Incident #126827-I, Incident #127589-I, Incident #127590-I, Incident #127601-I, Complaint #125236-C, and Complaint #125645-C.
Complaint Details
Investigation included two complaints (#125236-C and #125645-C) and multiple incidents; no deficiencies were found.
Findings
No deficiencies were cited during the investigation of the listed incidents and complaints.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 12, 2024
Visit Reason
Investigation of incidents and complaints including Incident #122508-I, Incident #124531-I, Complaint #122519-C, and Complaint #122611.
Complaint Details
Investigation involved multiple incidents and complaints; no deficiencies were found.
Findings
No deficiencies were cited during the investigation of the listed incidents and complaints.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 24, 2024
Visit Reason
The inspection was conducted to investigate Complaint #122240-C and Incident #122049-I at Hillcrest Family Services - RCF.
Complaint Details
Investigation of Complaint #122240-C and Incident #122049-I found no deficiencies.
Findings
No deficiencies were cited during the investigation of the complaint and incident.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 9, 2024
Visit Reason
The inspection was conducted as an investigation of incidents involving Resident #1, specifically incidents #120626-I and #120708-I, with a deficiency cited during the investigation of incident #120648-I related to supervision and staffing.
Complaint Details
The visit was complaint-related, investigating incidents involving Resident #1's elopement and supervision failures. The deficiency was cited based on these incidents. Substantiation status is not explicitly stated.
Findings
The facility failed to provide adequate supervision levels based on the present needs of Resident #1, who required 1:1 supervision due to risk of self-harm and elopement behaviors. Multiple incidents were documented where Resident #1 left the facility unsupervised, resulting in police involvement and hospital evaluation.
Deficiencies (1)
Staff failed to provide supervision levels based on the present needs of Resident #1, who required 1:1 supervision due to risk of self-harm and elopement.
Report Facts
Incident dates: 3
Residents reviewed: 3
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Apr 18, 2024
Visit Reason
The inspection was conducted to determine compliance with licensing rules for a Residential Care Facility, including review of incidents and complaints.
Findings
Multiple deficiencies were cited related to general requirements, supervision and staffing, resident records, dietary planning, and service plans. The facility failed to notify the Department of elopements timely and did not meet requirements for supervision and documentation of resident care.
Deficiencies (7)
Facility failed to notify the Department of elopements as required by Iowa Administrative Code rule 50.7(4).
Staff failed to provide supervision levels based on the present needs of residents, including inadequate safety checks for Resident C1.
Facility failed to have signed primary care provider orders completed quarterly for residents reviewed.
Facility failed to plan and follow a menu in accordance with dietary orders for residents.
Facility failed to develop a written, individualized, and integrated service plan within 30 days of admission for residents reviewed.
Facility failed to modify service plans to address changes in resident needs in a timely manner.
Facility failed to notify the director or designee within 24 hours or next business day when a resident eloped.
Report Facts
Residents reviewed for primary care provider orders: 4
Residents reviewed for dietary orders: 5
Residents reviewed for service plans: 4
Residents with elopement incidents reviewed: 3
Missing entries on safety head check data sheet: 37
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 2, 2023
Visit Reason
The inspection was conducted to investigate multiple incidents and complaints identified by their respective numbers: Incident #114367-I, Incident #114375-I, Incident #115672-I, Complaint #114719-C, and Complaint #114873-C.
Complaint Details
Investigation of multiple incidents and complaints resulted in no deficiencies cited.
Findings
No deficiencies were cited during the investigation of the listed incidents and complaints.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jul 19, 2023
Visit Reason
The inspection was conducted to investigate Complaint #113291-C regarding the facility's failure to meet nutritional needs of residents with special diets.
Complaint Details
Investigation of Complaint #113291-C found a dietary deficiency related to nutrition and menu planning. No deficiencies were cited for Complaint #114856-C and Incident #114058-I.
Findings
The facility failed to create and follow a menu to meet the nutritional needs of 2 residents with special diets during a meal observation. No menu or guidelines for special diet modifications were found, and the Administrator confirmed the lack of menu due to kitchen staff turnover.
Deficiencies (1)
Failed to create and follow a menu to meet the nutritional needs of 2 residents with special diets.
Report Facts
Complaint number: 113291
Complaint number: 114856
Incident number: 114058
Diet order date: Jul 13, 2023
Diet order date: May 20, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Bellini | Administrator | Signed Plan of Correction and mentioned in report |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Apr 27, 2023
Visit Reason
The inspection was conducted to investigate multiple complaints and incidents related to the facility's compliance with medication administration, service plans, resident activities, and housekeeping standards.
Complaint Details
The inspection investigated complaints #111085-C, #111412-C, #110733-C, and #111600-C. No deficiencies were cited for complaints #112502-C, #111592-C, #111155-C, and incidents #111975-I, #111248-I.
Findings
The facility was found deficient in consistently documenting medication administration for 6 residents, ensuring individualized service plans addressed all assessed needs for 1 resident, providing at least two organized group evening activities per week, and maintaining clean and orderly resident rooms free of refuse and pest infestations.
Deficiencies (4)
Failed to ensure medications were consistently documented as administered for 6 residents.
Failed to ensure service plans included all assessed needs for 1 resident.
Failed to include at least two organized group evening activities per week as part of the planned activity program.
Failed to ensure all rooms were kept in a clean, orderly condition free of refuse and pest infestations.
Report Facts
Residents reviewed for medication documentation: 6
Residents reviewed for service plans: 13
Census in rooms observed for housekeeping: 3
Dates of last pest control treatment: Jan 31, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Toni Healey | RN/Admin | Administrator who confirmed findings and signed plans of correction |
| Deb Dixon | Program Coordinator | Health Facilities Division, Department of Inspections and Appeals, signed plans of correction |
| Social Worker #2 | Interviewed regarding Resident #16's health concerns and service plan | |
| Activities Manager | Interviewed regarding lack of evening activities | |
| Staff A | Observed housekeeping issues and commented on pest control |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 19, 2023
Visit Reason
The inspection was conducted to investigate complaints #108478-C, #108722-C, and #108871-C, as well as an incident #109498-I involving Resident #1.
Complaint Details
The investigation found no deficiencies related to complaints #108478-C, #108722-C, and #108871-C. The cited deficiency was related to incident #109498-I. The Administrator confirmed the findings on 1/19/23.
Findings
No deficiencies were found related to the complaints; however, a deficiency was cited for failure to amend or change the service plan for Resident #1 despite multiple incidents of elopement and substance abuse and poor attendance at required groups.
Deficiencies (1)
Failure to amend or change the service plan for Resident #1 to address changing needs related to elopement prevention and relapse prevention.
Report Facts
Complaints investigated: 3
Incident investigated: 1
Service plans reviewed: 2
Elopement prevention groups per month: 2
Relapse prevention groups per month: 2
Resident #1 relapse prevention group attendance: 1
Resident #1 elopements with intoxication: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Toni Healey | RN/Admin | Signed the Plan of Correction |
| Deb Dixon | Program Coordinator | Authored the Plan of Correction document |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Oct 20, 2022
Visit Reason
The inspection was conducted to investigate multiple complaints and incidents, including Incident #107250-I, which involved a safety concern regarding a resident ingesting fingernail polish remover.
Complaint Details
The investigation included multiple complaints and incidents, with no deficiencies cited for most except for Incident #107250-I, which was substantiated based on the unsafe environment leading to Resident #6's toxic ingestion.
Findings
The facility failed to maintain a safe environment for residents, as evidenced by an incident where Resident #6 ingested fingernail polish remover left unsupervised at the tech station desk. Staff failed to secure hazardous materials as required by policy, leading to the resident's toxic ingestion and subsequent hospitalization.
Deficiencies (1)
Failure to ensure a safe environment for residents by leaving hazardous materials (fingernail polish remover) unsecured, resulting in Resident #6 ingesting the substance.
Report Facts
Incident date: Aug 21, 2022
Hospital observation duration: 24
Date of inspection: Oct 20, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Toni Healey | RN/Admin | Signed Plan of Correction |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 28, 2022
Visit Reason
The inspection was conducted as an investigation of Mandatory Report #106113-M regarding financial management concerns at Hillcrest Family Services - RCF.
Complaint Details
The investigation was triggered by Mandatory Report #106113-M. The complaint was substantiated based on interviews and record reviews showing missing receipts and improper handling of residents' funds.
Findings
The facility failed to maintain receipts for personal funds for 6 residents who required assistance with money management. Multiple stimulus payments and gift card expenditures lacked proper receipt documentation, and the Activities Director frequently did shopping without providing receipts despite repeated requests.
Deficiencies (1)
Failed to maintain receipts for personal funds for 6 residents requiring assistance with money management.
Report Facts
Stimulus money unaccounted for Resident #1 in 2020: 1110.37
Stimulus money unaccounted for Resident #1 in 2021: 1172.99
Stimulus money unaccounted for Resident #2 in 2020: 1152.49
Stimulus money unaccounted for Resident #2 in 2021: 1021.11
Stimulus money unaccounted for Resident #3 gift card: 284.94
Stimulus money unaccounted for Resident #4 gift card: 219.67
Stimulus money gift card amount for Residents #3, #4, #5, #6: 500
Total value of US bank Visa cards purchased by former payee: 20000
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Agency Representative Payee | Managed trust account and requested receipts from Activities Director |
| Staff A | Former Agency Payee | Purchased US bank Visa cards and requested receipts from Activities Director |
| Administrator | Expressed concern about Activities Director's handling of residents' money and confirmed findings | |
| Director of Finance | Started position in May 2022 and was aware of money bag carried by Activities Director | |
| Activities Director | Carried residents' money, did shopping, and failed to provide receipts despite requests |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 11, 2022
Visit Reason
The inspection was conducted as an investigation of complaint number 103547-A.
Complaint Details
Investigation of complaint 103547-A with no deficiencies found.
Findings
No deficiencies were cited during the investigation.
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 19, 2022
Visit Reason
The inspection was conducted as an investigation of Incident #104639-I involving a resident's elopement behaviors. The purpose was to determine compliance with service plan modifications following changes in the resident's condition.
Complaint Details
The investigation was triggered by Incident #104639-I involving multiple elopements by Resident C1. The deficiency was substantiated as the service plan was not updated to address the resident's new behaviors despite appropriate safety checks and follow-up actions.
Findings
The facility failed to modify the service plan to add goals and objectives addressing new elopement behaviors for one of three residents reviewed. Despite multiple elopement incidents, the service plan was not updated accordingly, as confirmed by staff and administrators.
Deficiencies (1)
Failure to modify service plans to add goals/objectives as resident needs changed, specifically related to elopement behaviors for Resident C1.
Report Facts
Incident dates: 4
Admission date: Oct 1, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff E | Stated she intended to amend Resident C1's service plan but did not due to closely timed events | |
| Director of Residential Services | Confirmed findings in the Administrator's absence | |
| RCF/PMI Administrator | Confirmed findings in the Administrator's absence | |
| Toni Healey | RN/Admin | Signed Plan of Correction |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 1, 2022
Visit Reason
The inspection was conducted due to investigations related to possible dependent adult abuse involving alleged sexual interactions between staff and a former resident.
Complaint Details
The visit was complaint-related, triggered by allegations of possible sexual interaction between staff and a former resident. The complaint was substantiated by findings that staff did not report the suspected abuse and training requirements were not met.
Findings
The facility failed to ensure policies regarding investigation and reporting of alleged dependent adult abuse were followed by staff. Two staff members did not report suspected sexual interactions between staff and residents. Additionally, one long-term staff member had not completed required dependent adult abuse training within the mandated timeframe.
Deficiencies (2)
Failure to follow policy regarding investigation and reporting of alleged dependent adult abuse involving possible sexual interaction between staff and a former resident.
Failure to ensure a long-term staff member completed required dependent adult abuse identification and reporting training every three years.
Report Facts
Date of employment: 2013
Date of last training certificate: 2014
Date of inspection: Mar 1, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Staff member who failed to report suspected abuse and had expired dependent adult abuse training. | |
| Staff B | Staff member who did not report suspected abuse. | |
| Staff C | Full-time social worker | Named in video and photo related to alleged abuse; had not been trained in dependent adult abuse. |
| Staff D | Mental health tech | Named in video and photo related to alleged abuse; had not been trained in dependent adult abuse. |
| Director of Residential Services | Confirmed no reports were received from staff regarding suspected abuse and confirmed expired training for Staff A. | |
| Administrator | Confirmed no reports were received from staff regarding suspected abuse. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 23, 2021
Visit Reason
The inspection was conducted as part of the investigation of Complaint #100156-C, including an onsite infection control survey.
Complaint Details
The deficiency was cited during the investigation of Complaint #100156-C. An onsite infection control survey was also conducted with no deficiencies cited.
Findings
The facility failed to ensure that service plans were modified to meet the needs of Resident #3, whose service plan had not been updated since admission despite ongoing behavioral issues and lack of progress on goals.
Deficiencies (1)
Failure to modify service plans to meet the needs of Resident #3, including updating goals and objectives as his condition and behaviors changed.
Report Facts
Residents reviewed: 5
Classes attended: 3
Classes attended: 5
Quarterly reviews: 2
Date of admission: May 3, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Deb Dixon | Program Coordinator | Signed Plan of Correction document |
| Toni Healey | RN/Admin | Approved Plan of Correction |
Inspection Report
Complaint Investigation
Deficiencies: 8
Date: Sep 2, 2021
Visit Reason
The inspection was conducted to investigate multiple incidents and complaints including Incident 98663-I, Incident 98056-I, Complaint 97388-C, Incident 99325-I, Complaint 98175-C, Incident 98055-I, Complaint 96472-C, and Complaint 98539-C, as well as an onsite infection control survey.
Complaint Details
The visit was complaint-related involving multiple incidents and complaints as listed in the initial comments section. The report notes no deficiencies were cited during investigation of some incidents (98663-I, 98056-I, 97388-C, 99325-I), but deficiencies were cited related to other complaints and incidents (98175-C, 98055-I, 96472-C, 98539-C).
Findings
The facility was found to have multiple deficiencies including failure to conduct in-service training on meal time procedures and resident activities, incomplete tuberculosis screening for personnel, improper medication administration for residents, failure to update service plans as residents' needs changed, inadequate staff training on dependent adult abuse identification and reporting, and insufficient supervision to prevent resident elopement. The facility also failed to complete two-step TB testing for some employees.
Deficiencies (8)
Failure to conduct in-service educational programming on meal time procedures/dietary topics during 2020.
Failure to conduct in-service educational programming on resident activities during 2020.
Failure to comply with tuberculosis testing requirements for personnel.
Failure to ensure all medication orders were properly implemented/administered by qualified personnel for 1 of 6 residents reviewed.
Failure to update/amend service plan as resident needs changed for 1 of 6 residents reviewed.
Failure to provide training relating to identification and reporting of dependent adult abuse for 1 of 4 staff reviewed.
Failure to provide adequate supervision to prevent hazard from residents for 2 of 6 residents reviewed, including multiple elopements.
Failure to complete two-step tuberculosis screening for 3 of 6 employees reviewed.
Report Facts
Residents reviewed for medication orders: 6
Residents reviewed for service plan update: 6
Staff reviewed for dependent adult abuse training: 4
Residents reviewed for supervision: 6
Employees reviewed for TB screening: 6
Dates of medication administration gaps: 15
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Jan 13, 2021
Visit Reason
The inspection was conducted as an investigation of multiple incidents and complaints alleging harassment and possible sexual assault involving residents at Hillcrest Family Services - RCF.
Complaint Details
The investigation involved multiple incidents and complaints (#92837-I, #93519-I, #93011-C, #93987-C, #94999-C, #93204-I) related to harassment and possible sexual assault between residents. The complaint was substantiated by interviews, timeline review, and staff statements indicating failure to increase supervision and communicate the incident properly.
Findings
The facility failed to provide adequate supervision based on the present needs of residents, specifically failing to prevent harassment and a possible sexual assault incident between residents. The investigation revealed staff did not increase supervision or properly communicate the severity of the incident to all shifts.
Deficiencies (1)
Facility failed to provide supervision based on present needs for 2 of 2 residents reviewed, resulting in harassment and possible sexual assault.
Report Facts
Incident numbers investigated: 6
Residents reviewed: 2
Time of incident: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff L | Reported interactions with residents, instructed Resident #2 to stay away from Resident #5, and communicated with Resident #5 about the incident. | |
| Staff G | Was at tech station when Resident #2 reported the rape and was surprised she was not informed earlier. | |
| Staff C | Reported Resident #2 was smiling and chatty and noted no mention of rape to her mother. | |
| Assistant Administrator | Conducted internal investigation and confirmed staff did not increase supervision after learning about the possible sexual assault. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 13, 2020
Visit Reason
Investigation of Complaint #90373-C and an onsite infection control survey.
Complaint Details
Complaint #90373-C was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint investigation or the infection control survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 5, 2020
Visit Reason
Investigation of Incident #88625-I.
Complaint Details
Investigation of Incident #88625-I with no deficiencies cited.
Findings
No deficiencies were cited during the investigation of Incident #88625-I.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 29, 2012
Visit Reason
Investigation of Incident #37924-I at Julien Care Facility-RCF.
Complaint Details
Investigation of Incident #37924-I with no deficiencies cited.
Findings
No deficiencies were cited during the investigation of Incident #37924-I.
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