Deficiencies (last 3 years)
Deficiencies (over 3 years)
4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
23% better than North Carolina average
North Carolina average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Deficiencies: 1
Date: Dec 9, 2025
Visit Reason
The inspection was conducted to assess compliance with regulations regarding accident hazards and supervision in a nursing home setting, specifically focusing on the safe transfer of residents using mechanical lifts.
Findings
The facility failed to safely transfer Resident #1 using a mechanical lift, resulting in a closed fracture of the right tibia. The incident involved the resident's right foot getting caught in the recliner footrest during transfer, leading to injury. The facility implemented corrective actions including staff re-education and monitoring to prevent recurrence.
Deficiencies (1)
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Report Facts
Deficiencies cited: 1
Completion date for corrective action: Nov 10, 2025
QAPI monitoring schedule: 4
QAPI monitoring schedule: 2
QAPI monitoring schedule: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse Aide #1 | Nurse Aide | Involved in the transfer incident with Resident #1 |
| Nurse Aide #5 | Nurse Aide | Assisted in the transfer incident with Resident #1 |
| Nurse #1 | Nurse | Notified of resident's injury and administered pain medication |
| Nurse #3 | Nurse | Assessed resident's injury and notified physician |
| Nurse #2 | Nurse Aide | Assisted in transferring Resident #1 and reported moaning sounds |
| Nurse #5 | Nurse | Received nursing report and coordinated emergency room transfer |
| Director of Nursing | Director of Nursing | Interviewed staff, confirmed incident details, and oversaw corrective actions |
| Medical Director | Medical Director | Interviewed regarding resident's condition and injury |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Mar 20, 2025
Visit Reason
The inspection was conducted as an annual survey of the nursing home facility Hillcrest Raleigh at Crabtree Valley to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection, indicating the facility met the required standards at the time of the survey.
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Dec 15, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with infection prevention and control requirements, specifically focusing on the disinfection practices of shared blood glucose meters.
Findings
The facility staff failed to disinfect a shared blood glucose meter between residents with an approved disinfectant wipe for 2 of 3 residents tested, potentially exposing residents to bloodborne infections. The facility had policies and education on proper disinfection, but observations and interviews revealed improper use of disinfectants and lack of approved wipes on medication carts.
Deficiencies (1)
Failure to disinfect a shared blood glucose meter between residents with an approved disinfectant wipe.
Report Facts
Residents affected: 2
Number of education topics acknowledged: 26
Date of observation: Dec 13, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #1 | Named in findings related to improper disinfection of shared glucometer | |
| Director of Nursing | Director of Nursing | Informed of the concern related to failure to use EPA-approved disinfectant |
| RN Supervisor | Registered Nurse Supervisor | Assisted in locating approved disinfectant wipes and confirmed correct wipes |
| Administrator | Facility Administrator | Informed of the concern and reported distribution of approved disinfectant wipes |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Dec 15, 2023
Visit Reason
The inspection was conducted based on complaints and concerns related to medication self-administration, accuracy of advanced directives, transmission of Minimum Data Set (MDS) assessments, and infection control practices including glucometer disinfection.
Complaint Details
The visit was complaint-related, triggered by concerns about medication self-administration, advanced directive accuracy, MDS transmission failures, and infection control practices related to glucometer disinfection. Substantiation status is not explicitly stated.
Findings
The facility failed to properly assess and document medication self-administration for a resident, maintain accurate and consistent advanced directive documentation, transmit MDS assessments to CMS within required timeframes, and properly disinfect shared glucometers between residents, potentially exposing residents to bloodborne infections.
Deficiencies (4)
Failed to determine clinical appropriateness and obtain physician orders for self-administration of medications for Resident #44.
Failed to maintain accurate advanced directive (code status) information for Resident #9, resulting in discrepancies between EMR, paper chart, and physician orders.
Failed to ensure Minimum Data Set (MDS) assessments were transmitted and accepted by CMS database for 26 residents.
Failed to disinfect shared blood glucose meter between residents with an approved disinfectant, risking spread of bloodborne infections.
Report Facts
Residents reviewed for advanced directives: 29
Residents reviewed for MDS transmission: 26
Residents affected by glucometer disinfection failure: 2
Date of inspection completion: Dec 15, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nurse #1 | Nurse | Named in infection control deficiency related to improper glucometer disinfection. |
| RN Supervisor | Registered Nurse Supervisor | Interviewed regarding medication self-administration process and glucometer disinfection. |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding medication self-administration policies and advanced directive discrepancies. |
| Social Worker #1 | Social Worker | Interviewed regarding Resident #9's advance directive status. |
| Social Worker #2 | Social Worker | Interviewed regarding Resident #9's advance directive status. |
| Administrator | Facility Administrator | Interviewed regarding MDS transmission issues and infection control concerns. |
Inspection Report
Routine
Deficiencies: 6
Date: Sep 16, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, care planning, medication management, medication storage, food safety, and resident privacy.
Findings
The facility was found deficient in timely completion of Minimum Data Set (MDS) assessments including admission, annual, quarterly, and significant change assessments. Baseline care plans were not consistently developed within 48 hours to address residents' immediate needs. Psychotropic medication orders lacked required stop dates. Medication storage practices were deficient including unlabeled and expired medications, improper storage conditions, and failure to label opened medications. Food safety issues included unlabeled and undated leftover food items and improper drying of dishware. Privacy curtains in some rooms were not wide enough to provide full visual privacy.
Deficiencies (6)
Failed to complete admission, annual, quarterly, and significant change Minimum Data Set (MDS) assessments timely for multiple residents.
Failed to develop resident-centered baseline care plans within 48 hours addressing dementia, mobility, and falls for some residents.
Psychotropic medication orders (lorazepam) given on PRN basis lacked stop dates for 2 residents.
Medication storage deficiencies including unlabeled opened injectable medications, expired medications not discarded, and medications stored outside manufacturer instructions.
Leftover food items in nourishment refrigerators were not labeled or dated; perishable items improperly stored; cups and dessert bowls not air dried before use.
Privacy curtains in 2 rooms did not provide full visual privacy around beds.
Report Facts
Residents reviewed for MDS assessments: 40
Residents with late quarterly MDS assessments: 12
Residents reviewed for baseline care plans: 17
Residents receiving PRN psychotropic medication: 2
Medication doses administered: 11
Medication doses administered: 4
Rooms with insufficient privacy curtains: 2
Nourishment refrigerators with unlabeled food items: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS Nurse #1 | Interviewed regarding late MDS assessments and baseline care plans | |
| Administrator | Interviewed regarding expectations for MDS assessments, baseline care plans, medication orders, nourishment room policies, and privacy curtains | |
| Nurse #1 | Interviewed regarding medication order entry and nourishment room management | |
| Nurse Supervisor | Interviewed regarding baseline care plans and medication orders | |
| Director of Nursing | DON | Interviewed regarding expectations for MDS assessments, medication orders, and medication storage |
| Certified Dietary Manager | CDM | Interviewed regarding nourishment room observations and food safety |
| Nurse #2 | Observed medication storage and interviewed regarding labeling | |
| Nurse #3 | Observed medication storage and interviewed regarding labeling and expired medications | |
| Maintenance Director | Interviewed regarding privacy curtains | |
| Nurse Aide #1 | Interviewed regarding privacy curtain use | |
| Consultant Pharmacist | Interviewed regarding medication order stop dates |
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