Inspection Reports for
Hillcrest Home

The complaint investigation revealed that Resident #55, who was at moderate risk for wandering, eloped multiple times including on 2/28/2025 when a visitor allowed the resident to exit through the front door after the door alarm system released the lock following a 15-second delay. The system was not routinely monitored or tested as recommended, and staff were unaware of manufacturer guidelines. The resident was placed on 30-minute checks after the incident.

The facility failed to provide adequate supervision and failed to monitor and test the alert alarm system per manufacturer recommendations, resulting in Resident #55 eloping from the facility multiple times. The door alarm system was found to have malfunctioned, and staff were not routinely checking or aware of manufacturer monitoring requirements. The facility had policies and interventions in place but failed in execution and monitoring.

The complaint investigation revealed that Resident #55, a high-risk resident for wandering and elopement, eloped multiple times including on 2/28/2025 when a visitor held the door open allowing the resident to exit. The alert alarm system was not routinely monitored or tested as recommended, and staff were not alerted promptly during alarms. The system had sensor malfunctions and wiring issues that were only addressed after the incident.

The facility failed to provide adequate supervision and failed to monitor and test the alert alarm system per manufacturer recommendations, resulting in Resident #55 eloping from the facility multiple times, including an incident on 2/28/2025 where a visitor inadvertently allowed the resident to exit. The alarm system had sensor and wiring issues that were not routinely checked, and staff response to alarms was delayed.

The facility failed to ensure that two sampled residents (#44 and #78) had their facial hair trimmed and nails properly maintained, with observations of chipped nail polish and long facial hair. Staff confirmed the residents needed nail care and facial hair removal, and a policy on activities of daily living was reviewed.

The complaint investigation found that Resident #1 was burned by a hot hand warmer given by the speech therapist during therapy. The resident could not recall who gave it to him initially, but later identified the speech therapist. The speech therapist admitted to giving the hot pack without a physician's order. Retraining was provided to the speech therapist on the risks and proper use of hot packs.

The facility failed to ensure adequate supervision to prevent burns, resulting in Resident #1 sustaining a first-degree burn from a hot hand warmer given by the speech therapist without a physician's order. The speech therapist admitted to giving the hot pack, and retraining was provided to staff on the risks of hot packs and proper procedures.

The facility failed to develop comprehensive, person-centered care plans addressing insulin administration and monitoring for Resident #46, did not revise the care plan to reflect the current needs of Resident #66 requiring extensive assistance with eating, allowed Nursing Assistants to work beyond four months without completing certification, and failed to provide timely laboratory services for physician-ordered tests.