Inspection Reports for
Hillcrest Home

The complaint investigation was substantiated with findings that Resident #55 eloped multiple times due to inadequate supervision and alarm system failures. The resident was found outside the facility on several occasions, including a documented incident on 2/28/2025 where the door alarm system failed to prevent exit.

The facility failed to provide adequate supervision and did not monitor or test the alert alarm system according to 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 malfunctions and lacked routine checks, and staff were not fully aware of manufacturer monitoring requirements.

The complaint investigation was substantiated as Resident #55 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 education and drills were insufficient.

The facility failed to ensure adequate supervision and proper monitoring/testing of the alert alarm system, resulting in Resident #55 eloping from the facility multiple times, including an incident on 2/28/2025 where a visitor held the door open allowing the resident to exit. The alarm system was not routinely checked per manufacturer recommendations, and staff were not fully aware of monitoring requirements.

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. This deficiency potentially affected 16 residents residing on the 300 Hall.

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 the resident was given a hot hand warmer by the speech therapist during therapy, which caused a burn. The speech therapist admitted to giving the hot pack without a physician's order and was retrained on the risks and proper procedures. The resident's spouse and staff interviews confirmed the incident.

The facility failed to ensure adequate supervision to prevent burns for one resident who received speech therapy. The resident sustained a first-degree burn on the left thigh caused by a hot pack given by the speech therapist without a physician's order, contrary to facility policy and manufacturer guidelines.

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 for residents requiring insulin and extensive assistance with eating, failed to ensure nursing assistants completed certification within four months, and failed to provide timely laboratory services as ordered by the physician.

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.