Inspection Reports for Hillcrest Village
203 Sparks Ave, Jeffersonville, IN 47130, United States, IN, 47130
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 23, 2025, found no deficiencies related to complaint investigations. Earlier inspections showed a pattern of medication administration and documentation issues, along with Life Safety Code deficiencies involving egress accessibility, door self-closure, and electrical equipment maintenance. Several complaints were substantiated with deficiencies related to medication errors, resident care coordination, and reporting requirements, but many complaint investigations were unsubstantiated or corrected upon follow-up. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s record shows some improvement in recent months, with the latest inspections indicating compliance after prior citations.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
22.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
431% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
123 residents
Based on a June 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 123
Deficiencies: 0
Jun 23, 2025
Visit Reason
This visit was conducted for the investigation of complaints IN00460693 and IN00461229.
Findings
No deficiencies related to the allegations in complaints IN00460693 and IN00461229 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00460693 and Complaint IN00461229 were investigated with no deficiencies cited related to the allegations.
Report Facts
Census Bed Type - SNF/NF: 108
Census Bed Type - SNF: 15
Total Census: 123
Census Payor Type - Medicare: 10
Census Payor Type - Medicaid: 71
Census Payor Type - Other: 42
Inspection Report
Re-Inspection
Census: 120
Deficiencies: 0
May 29, 2025
Visit Reason
This visit was for the Post Survey Revisit (PSR) to the Investigation of Complaint IN00456231 completed on 2025-05-02, and was conducted in conjunction with the Investigation of Complaint IN00459509.
Findings
Complaint IN00456231 was corrected, and no deficiencies related to Complaint IN00459509 were cited. The facility was found to be in compliance with relevant federal and state regulations.
Complaint Details
Complaint IN00456231 was corrected; Complaint IN00459509 had no deficiencies related to the allegation cited.
Report Facts
Census SNF/NF: 105
Census SNF: 15
Total Census: 120
Medicare Census: 10
Medicaid Census: 72
Other Payor Census: 38
Inspection Report
Complaint Investigation
Census: 120
Deficiencies: 0
May 29, 2025
Visit Reason
This visit was for the Investigation of Complaint IN00459509 and was conducted in conjunction with the Post Survey Revisit to the Investigation of Complaint IN00456231 completed on 2025-05-02.
Findings
No deficiencies related to Complaint IN00459509 were cited. Complaint IN00456231 was corrected. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the Investigation of Complaint IN00459509.
Complaint Details
Complaint IN00459509 was investigated with no deficiencies cited. Complaint IN00456231 was previously investigated and corrected.
Report Facts
Census SNF/NF: 105
Census SNF: 15
Total Census: 120
Census Medicare: 10
Census Medicaid: 72
Census Other: 38
Survey Dates: 2
Inspection Report
Complaint Investigation
Deficiencies: 2
May 2, 2025
Visit Reason
The inspection was conducted as a complaint investigation related to medication administration practices at Hillcrest Village nursing home.
Findings
The facility failed to ensure blood pressure medications were held for out-of-parameter readings for 2 of 3 residents reviewed, and failed to ensure accurate documentation of narcotic medication administration for 3 of 4 residents reviewed.
Complaint Details
This citation relates to Complaint IN00456231.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure blood pressure medications were held for out-of-parameter readings for Resident B and Resident D. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents' medication administration records accurately reflected the administration of narcotic medications for Resident C, Resident D, and Resident E. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication administration instances: 12
Medication administration instances: 18
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 6 | Licensed Practical Nurse | Interviewed and indicated blood pressure medications should not be administered with out-of-range parameters and medication administration records should be signed out when narcotics are administered. |
| Director of Nursing | Director of Nursing | Provided a current copy of the Controlled Substances policy document during the inspection. |
Inspection Report
Complaint Investigation
Census: 113
Deficiencies: 2
May 1, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00456231 regarding allegations related to medication administration and documentation.
Findings
The facility failed to ensure blood pressure medications were held for out-of-parameter readings for 2 of 3 residents reviewed, and failed to ensure accurate documentation of narcotic medication administration for 3 of 4 residents reviewed.
Complaint Details
Complaint IN00456231 was substantiated with federal/state deficiencies cited at F684 related to medication administration errors.
Severity Breakdown
SS=D: 1
SS=E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to hold blood pressure medications for out-of-parameter readings for 2 of 3 residents. | SS=D |
| Failed to ensure medication administration records accurately reflected administration of narcotic medications for 3 of 4 residents. | SS=E |
Report Facts
Census: 113
SNF/NF beds: 104
SNF beds: 9
Medicare residents: 9
Medicaid residents: 71
Other payor residents: 33
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mark Bowman | Executive Director | Signed the report |
| Licensed Practical Nurse 6 | Interviewed regarding medication administration procedures | |
| Director of Nursing | Provided policy document and involved in corrective action plans |
Inspection Report
Follow-Up
Census: 118
Capacity: 149
Deficiencies: 1
Apr 3, 2025
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 02/20/25 by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
Hillcrest Village was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the NFPA 101 Life Safety Code. The facility is fully sprinklered with a fire alarm system and smoke detection throughout. However, the requirement for electrical equipment testing and maintenance was not met, though a temporary waiver was approved until 05/28/25.
Severity Breakdown
SS=F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Electrical Equipment - Testing and Maintenance Requirements not met as evidenced by failure to comply with NFPA 101 and NFPA 99 standards. | SS=F |
Report Facts
Facility capacity: 149
Census: 118
Temporary waiver expiration date: May 28, 2025
Inspection Report
Complaint Investigation
Census: 120
Capacity: 120
Deficiencies: 0
Mar 9, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00452483.
Findings
No deficiencies related to the allegations in Complaint IN00452483 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00452483 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census SNF/NF beds: 105
Census SNF beds: 15
Total census: 120
Payor type Medicare: 12
Payor type Medicaid: 69
Payor type Other: 39
Inspection Report
Annual Inspection
Deficiencies: 0
Mar 4, 2025
Visit Reason
The visit was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.
Findings
Hillcrest Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Life Safety
Census: 117
Capacity: 149
Deficiencies: 9
Feb 20, 2025
Visit Reason
The survey was conducted as a Life Safety Code Recertification and State Licensure Survey by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and NFPA 101, Life Safety Code.
Findings
The facility was found not in compliance with several Life Safety Code requirements including corridor obstructions, egress door accessibility, self-closing doors to hazardous areas, sprinkler system maintenance, electrical equipment testing, and oxygen storage signage. Corrective actions were planned or implemented for all deficiencies.
Severity Breakdown
SS=E: 8
SS=F: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to ensure 1 of over 10 corridor means of egress was continuously maintained free of obstructions (stationary pedestal fan in corridor). | SS=E |
| Failed to ensure 1 of over 8 means of egress was continuously maintained free of all obstructions or impediments (lift and wheelchair blocking exit door). | SS=E |
| Failed to ensure means of egress through reception main exit was readily accessible; exit door was magnetically locked without posted code. | SS=E |
| Failed to ensure 2 of over 30 corridor doors to hazardous area enclosures were self-closing and kept closed; doors held open with chairs and carts. | SS=E |
| Failed to ensure 4 of over 15 hazardous area doors were provided with properly working self-closing devices; one door not equipped, others obstructed. | SS=E |
| Failed to maintain ceiling construction of Therapy Storage Closet; missing ceiling tile could delay sprinkler activation. | SS=E |
| Failed to conduct required maintenance and maintain documentation for Patient Care Related Electrical Equipment (PCREE). | SS=F |
| Failed to ensure oxygen storage location was provided with a precautionary 'No Smoking' sign. | SS=E |
| Failed to ensure oxygen transfilling location was provided with a precautionary 'No Smoking' sign. | SS=E |
Report Facts
Certified beds: 149
Census: 117
Residents affected by corridor obstruction: 25
Residents affected by exit obstruction: 12
Residents affected by locked exit door: 24
Residents affected by self-closing door issues: 15
Residents affected by hazardous area door issues: 30
Residents affected by sprinkler ceiling issue: 5
Residents affected by electrical equipment testing deficiency: all
Residents affected by oxygen storage signage deficiency: 10
Residents affected by oxygen transfilling signage deficiency: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mark Bowman | Executive Director | Signed report and present at exit conference |
| Maintenance Supervisor | Interviewed during observations and acknowledged findings | |
| Administrator | Interviewed during observations and acknowledged findings |
Inspection Report
Annual Inspection
Deficiencies: 2
Jan 31, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care and pharmaceutical services at Hillcrest Village nursing home.
Findings
The facility failed to ensure consistent provision of showers for one resident and timely administration of medications for two residents. Documentation deficiencies and delays in medication delivery were noted, with minimal harm or potential for actual harm to residents.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure showers were provided consistently for 1 of 3 residents reviewed for Activities of Daily Living care (Resident 84). | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a resident received medications as ordered and administered in a timely manner for 2 of 3 residents reviewed for pharmacy services (Residents 62 and 64). | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for Activities of Daily Living care: 3
Residents reviewed for pharmacy services: 3
Missed shower dates: 6
Medication doses missed or delayed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Aide (CNA) 4 | Interviewed regarding shower documentation and care | |
| Certified Nursing Aide (CNA) 5 | Interviewed regarding shower documentation and care | |
| Licensed Practical Nurse (LPN) 3 | Interviewed regarding shower documentation and medication delivery | |
| Director of Nursing (DON) | Interviewed regarding shower documentation and medication approval process | |
| Nurse Practitioner (NP) | Notified regarding medication needs and orders |
Inspection Report
Renewal
Census: 121
Capacity: 121
Deficiencies: 2
Jan 31, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from January 27 to January 31, 2025.
Findings
The facility was found deficient in providing consistent showers for dependent residents and timely administration of medications as ordered for pharmacy services. Specific deficiencies involved one resident not receiving showers as scheduled and two residents not receiving medications in a timely manner.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure showers were provided consistently for 1 of 3 residents reviewed for Activities of Daily Living care (Resident 84). | SS=D |
| Failed to ensure a resident received medications as ordered and administered in a timely manner for 2 of 3 residents reviewed for pharmacy services (Residents 62 and 64). | SS=D |
Report Facts
Census: 121
Total Capacity: 121
Medicare Residents: 17
Medicaid Residents: 82
Other Residents: 22
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mark Bowman | Executive Director | Signed the report |
| Licensed Practical Nurse 3 | LPN | Interviewed regarding medication administration and shower documentation |
| Certified Nursing Aide 4 | CNA | Interviewed regarding shower documentation |
| Certified Nursing Aide 5 | CNA | Interviewed regarding shower documentation |
| Director of Nursing | DON | Interviewed regarding shower documentation and medication administration |
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 6, 2025
Visit Reason
Paper compliance review related to the Investigation of Complaint IN00444619 completed on November 8, 2024.
Findings
Hillcrest Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper review of the complaint investigation.
Complaint Details
Investigation of Complaint IN00444619 was completed and corrected.
Inspection Report
Complaint Investigation
Census: 115
Deficiencies: 0
Dec 20, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00447150.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00447150 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 115
Census Payor Type - Medicare: 13
Census Payor Type - Medicaid: 21
Census Payor Type - Other: 81
Census Bed Type - SNF/NF: 33
Census Bed Type - NF: 73
Census Bed Type - SNF: 9
Inspection Report
Complaint Investigation
Deficiencies: 4
Nov 8, 2024
Visit Reason
The inspection was conducted as a complaint investigation related to medication self-administration, notification of change in condition, quality of care, and medical record accuracy for Resident B.
Findings
The facility failed to ensure proper medication self-administration assessments and physician orders, timely notification to physicians of out-of-parameter blood pressures, adequate monitoring and interventions for a resident with hypertension and cardiovascular accident, and accurate documentation of medication administration in medical records.
Complaint Details
This Citation relates to Complaint IN00444619.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure medications for a resident without a self-administration assessment were not left at bedside. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to notify physician when resident's blood pressure was not within set parameters. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure increased monitoring and interventions for a resident with consistent high blood pressures and history of cardiovascular accident. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure resident's record accurately reflected administration of medications. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed: 3
Medication tablets observed: 6
Blood pressure readings out of parameter: 40
Hydralazine dosage: 25
Hydralazine dosage: 50
Clonidine dosage: 0.1
Metformin dosage: 500
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 4 | Licensed Practical Nurse | Interviewed regarding medication self-administration and resident medication refusals. |
| Director of Nursing | Director of Nursing | Provided policy documents and confirmed lack of medication self-administration assessment. |
| Nurse Practitioner 12 | Nurse Practitioner | Interviewed regarding expectations for notification of blood pressure changes. |
| Nurse Practitioner 22 | Nurse Practitioner | Interviewed regarding resident's medication noncompliance and treatment plan. |
| Licensed Practical Nurse 5 | Licensed Practical Nurse | Interviewed regarding medication administration documentation procedures. |
Inspection Report
Complaint Investigation
Census: 118
Capacity: 118
Deficiencies: 4
Nov 6, 2024
Visit Reason
This visit was for the investigation of complaints IN00444619, IN00445272, and IN00446007. Complaint IN00444619 resulted in federal/state deficiencies related to the allegations, while the other complaints had no deficiencies cited.
Findings
The facility was found deficient in multiple areas related to complaint IN00444619, including failure to ensure medications were not left at bedside without proper assessment, failure to notify physicians of out-of-parameter blood pressures, failure to ensure increased monitoring and interventions for a resident with consistent high blood pressures, and failure to accurately document medication administration.
Complaint Details
Complaint IN00444619 was substantiated with federal/state deficiencies cited at F554, F580, F684, and F842. Complaints IN00445272 and IN00446007 were not substantiated with deficiencies.
Severity Breakdown
SS=D: 3
SS=E: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure medications for a resident without a self-administration assessment were not left at bedside. | SS=D |
| Failed to ensure the physician was notified when a resident's blood pressure was not within set parameters. | SS=E |
| Failed to ensure increased monitoring and interventions were in place for a resident with consistent high blood pressures and history of cardiovascular accident. | SS=D |
| Failed to ensure a resident's record accurately reflected the administration of medications. | SS=D |
Report Facts
Census: 118
Total Capacity: 118
Residents with hypertension diagnosis: 1
Medication administration omissions: 9
Survey dates: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mark Bowman | Executive Director | Signed the inspection report |
| Nurse Practitioner 22 | Nurse Practitioner | Interviewed regarding resident's blood pressure management and medication compliance |
| Licensed Practical Nurse 4 | Licensed Practical Nurse | Interviewed regarding resident medication refusals and observations |
| Licensed Practical Nurse 5 | Licensed Practical Nurse | Interviewed regarding medication administration documentation |
| Director of Nursing | Director of Nursing | Provided policies and interviewed regarding medication self-administration and change of condition notifications |
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 15, 2024
Visit Reason
Paper compliance review to the Investigation of Complaint IN00436365 completed on July 23, 2024.
Findings
Hillcrest Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review to the Complaint Investigation.
Complaint Details
Investigation of Complaint IN00436365 completed on July 23, 2024; facility found in compliance.
Inspection Report
Complaint Investigation
Census: 119
Deficiencies: 2
Jul 23, 2024
Visit Reason
This visit was conducted for the investigation of complaints IN00436365 and IN00437950 at Hillcrest Village.
Findings
Complaint IN00436365 resulted in federal/state deficiencies related to failure to report alleged abuse and failure to ensure proper quality of care regarding blood pressure monitoring prior to medication administration. Complaint IN00437950 had no deficiencies cited.
Complaint Details
Complaint IN00436365 was substantiated with deficiencies cited at F609 (Reporting of Alleged Violations) and F684 (Quality of Care). Complaint IN00437950 was not substantiated with no deficiencies cited.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility management failed to report an incident of verbal abuse involving Resident B to the Indiana Department of Health. | SS=D |
| Facility failed to ensure Resident D's blood pressure was obtained prior to medication administration as ordered. | SS=D |
Report Facts
Census: 119
SNF/NF beds: 104
SNF beds: 15
Medicare residents: 16
Medicaid residents: 70
Other payor residents: 33
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN 7 | Licensed Practical Nurse | Named in verbal abuse incident with Resident B |
| LPN 6 | Licensed Practical Nurse | Received report of verbal abuse from Resident B and reported to Executive Director |
| LPN 8 | Licensed Practical Nurse | Interviewed regarding blood pressure monitoring and medication administration |
| Executive Director | Interviewed regarding reporting of abuse allegations | |
| Director of Nursing | Provided facility policies and described corrective actions and monitoring |
Inspection Report
Complaint Investigation
Deficiencies: 2
Jul 23, 2024
Visit Reason
The inspection was conducted in response to Complaint IN00436365, focusing on allegations of verbal abuse and quality of care concerns related to medication administration.
Findings
The facility failed to report an allegation of verbal abuse by a staff member towards a resident and failed to ensure a resident's blood pressure was obtained prior to medication administration as ordered. Both deficiencies were cited with minimal harm and affected a few residents.
Complaint Details
The complaint involved allegations of verbal abuse by staff and concerns about medication administration practices. The verbal abuse allegation was not reported as required, and blood pressure monitoring prior to medication administration was not documented as ordered.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility management failed to report an incident of verbal abuse by a Licensed Practical Nurse towards a resident to the Indiana Department of Health. | Level of Harm - Minimal harm or potential for actual harm |
| Facility failed to ensure a resident's blood pressure was obtained prior to medication administration as ordered. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Date of clinical record review: Jul 22, 2024
Medication administration dates missing blood pressure documentation: 3
Physician order date: May 22, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 7 | Named in verbal abuse incident with Resident B. | |
| Licensed Practical Nurse 6 | Received report of verbal abuse from Resident B and reported to Executive Director. | |
| Executive Director | Interviewed and indicated no prior report of verbal abuse was received. | |
| Licensed Practical Nurse 8 | Interviewed regarding blood pressure documentation prior to medication administration. | |
| Director of Nursing | Provided policy documents related to abuse reporting and medication administration. |
Inspection Report
Complaint Investigation
Census: 119
Deficiencies: 0
Jun 5, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00433783.
Findings
No deficiencies related to the complaint allegation were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Complaint Details
Complaint IN00433783 was investigated and found to have no deficiencies related to the allegation.
Report Facts
Census: 119
Census SNF/NF beds: 104
Census SNF beds: 15
Census Payor Type Medicare: 19
Census Payor Type Medicaid: 69
Census Payor Type Other: 31
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 12, 2024
Visit Reason
The document reports on paper compliance to the Post Survey Revisit (PSR) that exited on 03/21/24 for the Life Safety Code Recertification and State Licensure Survey that exited on 01/17/24.
Findings
Hillcrest Village was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Complaint Investigation
Census: 121
Deficiencies: 0
Mar 28, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00429596.
Findings
No deficiencies related to the allegations of Complaint IN00429596 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00429596 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 121
SNF/NF beds: 106
SNF beds: 15
Medicare residents: 17
Medicaid residents: 71
Other payor residents: 33
Inspection Report
Re-Inspection
Census: 120
Capacity: 149
Deficiencies: 3
Mar 21, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey was conducted to verify correction of previously cited deficiencies.
Findings
The facility was found not in compliance with Life Safety Code requirements related to cross-corridor door self-closure and latching, vertical openings enclosure, and improper use of power strips in patient care areas. Repairs and corrective actions were completed by 03/26/2024, and ongoing audits were planned to ensure continued compliance.
Severity Breakdown
SS=E: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure 1 of 13 cross-corridor door sets would self close and latch into the door frame per LSC 4.6.12.3. | SS=E |
| Failed to maintain protection of 1 of 5 interior stairwells; stairwell door failed to latch and was 'dogged down' despite having a 90 minute fire resistance rating label. | SS=E |
| Failed to ensure 1 of 1 extension cords including power strips were not used as a substitute for fixed wiring in room 140. | SS=E |
Report Facts
Deficiencies cited: 3
Census: 120
Total Capacity: 149
Cross-corridor doors: 13
Cross-corridor doors failing to latch: 2
Interior stairwells: 5
Stairwells failing to latch: 1
Residents potentially affected by power strip issue: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mark Bowman | Executive Director | Reviewed findings and corrective actions during exit conference. |
| Maintenance Supervisor | Observed deficiencies and agreed on corrective actions; participated in exit conference. | |
| Maintenance Director | Conducted audits, coordinated repairs, and responsible for ongoing compliance monitoring. |
Inspection Report
Complaint Investigation
Census: 122
Deficiencies: 0
Feb 9, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00424937.
Findings
No deficiencies related to the allegations of Complaint IN00424937 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00424937 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type - SNF/NF: 107
Census Bed Type - SNF: 15
Census Total: 122
Census Payor Type - Medicare: 12
Census Payor Type - Medicaid: 69
Census Payor Type - Other: 41
Census Payor Type - Total: 122
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 30, 2024
Visit Reason
Paper compliance review for the Annual Recertification and State Licensure survey, including the Investigation of Complaint IN00423583 completed on December 14, 2023.
Findings
Hillcrest Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey and the complaint investigation.
Complaint Details
Investigation of Complaint IN00423583 completed on December 14, 2023; facility found in compliance.
Inspection Report
Life Safety
Census: 116
Capacity: 149
Deficiencies: 11
Jan 17, 2024
Visit Reason
The survey was conducted as a Life Safety Code Recertification and State Licensure Survey by the Indiana Department of Health in accordance with 42 CFR 483.90(a) and NFPA 101 standards.
Findings
The facility was found not in compliance with several Life Safety Code requirements including cross-corridor door self-closing and latching, building construction fire rating, egress door locking arrangements, vertical openings enclosure, hazardous area enclosure, sprinkler system installation and maintenance, electrical equipment use, and oxygen storage and transfilling signage.
Severity Breakdown
SS=E: 9
SS=F: 2
Deficiencies (11)
| Description | Severity |
|---|---|
| Failed to ensure 2 of 13 cross-corridor door sets would self close and latch into the door frame per LSC 4.6.12.3. | SS=E |
| Failed to maintain the limited noncombustible rating in accordance with LSC Table 19.1.6.1 due to unprotected structural steel i-beams in wheelchair storage room. | SS=F |
| Failed to ensure means of egress through 4 of 4 stairwell exits was readily accessible without specialized security measures; keypad codes were not readily known. | SS=F |
| Failed to maintain protection of 1 of 5 interior stairwells; stairwell door failed to latch and was dogged down. | SS=E |
| Failed to maintain ceiling construction for 1 of 1 ground floor Therapy Rooms; annular space around electrical conduits not firestopped. | SS=E |
| Failed to ensure hazardous areas such as fuel fired heater rooms were separated from other spaces by smoke resistant partitions and doors; holes noted in ceiling of wheelchair storage room. | SS=E |
| Failed to maintain ceiling construction for 1 of 3 ceilings; gaps and cracks noted in sprinkler escutcheons in multiple rooms. | SS=E |
| Failed to maintain sprinkler system; sprinkler piping was used to support non-system components such as bundled cables and wires. | SS=E |
| Failed to ensure 3 of 3 extension cords including power strips were not used as a substitute for fixed wiring in patient care vicinities. | SS=E |
| Failed to provide oxygen storage location with a precautionary sign indicating no smoking in the immediate area. | SS=E |
| Failed to provide oxygen transfilling location with a precautionary sign indicating no smoking in the immediate area. | SS=E |
Report Facts
Certified beds: 149
Census: 116
Cross-corridor doors: 13
Cross-corridor doors failed to latch: 2
Stairwell exits: 4
Stairwell doors: 5
Storage areas audited: 41
Oxygen cylinders: 22
Liquid oxygen containers: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mark Bowman | Executive Director | Named during exit conference and plan of correction |
| Maintenance Supervisor | Participated in observations and interviews regarding deficiencies | |
| Maintenance Director | Responsible for audits, education, and corrective actions |
Inspection Report
Complaint Investigation
Deficiencies: 7
Dec 14, 2023
Visit Reason
The inspection was conducted due to complaints regarding medication administration oversight, resident concerns about food quality and temperature, social services follow-up, pharmaceutical services, and meal/snack service timing.
Findings
The facility failed to ensure appropriate oversight of medication administration, timely reporting of abuse allegations, adequate social services follow-up for residents with mental health concerns, accurate narcotic documentation, availability of antibiotics, and proper food temperature and palatability. Additionally, meals were not consistently served at designated times and nourishing snacks were not reliably offered at night.
Complaint Details
The complaint investigation included issues related to medication administration oversight, food quality and temperature, social services follow-up, pharmaceutical services, and meal/snack service timing. The allegation of neglect and mistreatment for Resident B was not reported to the State as required.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 7
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure appropriate oversight of medication administration during 5 of 25 random observations. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to act upon resident concerns of food temperatures, taste of food, drinks not being passed at meal times, and medications being left at bedside. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to timely report an allegation of neglect and mistreatment to the administrator and other officials in accordance with State law. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure appropriate social services follow-up and monitoring of residents with hallucinations, concerns, and mood changes. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure accurate documentation in the Controlled Drug Administration Record sheets of administered narcotics and failed to ensure oral and intravenous antibiotics were available for administration. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure food and drink were palatable, attractive, and at a safe and appetizing temperature. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure meals and snacks were served at times in accordance with resident needs, preferences, and requests, and failed to provide suitable and nourishing alternative meals and snacks for residents who want to eat at non-traditional times. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication administration observations: 5
Resident Council meetings with unresolved concerns: 8
Food Advisory Committee meetings with unresolved concerns: 6
Residents affected by food and meal service deficiencies: 116
Residents receiving narcotics with documentation issues: 3
Residents reviewed for social services follow-up: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN 20 | Registered Nurse | Named in medication administration oversight finding related to Resident 104. |
| LPN 21 | Licensed Practical Nurse | Named in medication administration oversight finding related to Resident 98. |
| LPN 14 | Licensed Practical Nurse | Named in medication administration oversight finding related to Resident 134. |
| Unit Manager 16 | Unit Manager | Named in medication administration oversight finding related to Resident 97. |
| Unit Manager 3 | Unit Manager | Named in failure to report allegation of neglect and mistreatment for Resident B. |
| Human Resources Director | Human Resources Director | Named in failure to report allegation of neglect and mistreatment for Resident B. |
| DON | Director of Nursing | Named in failure to report allegation of neglect and mistreatment for Resident B and medication availability. |
| SSA | Social Service Assistant | Named in social services follow-up deficiency. |
| SSD | Social Services Director | Named in social services follow-up deficiency. |
| LPN 11 | Licensed Practical Nurse | Named in narcotic documentation deficiency. |
| RN 12 | Registered Nurse | Named in narcotic documentation deficiency. |
| RN 19 | Registered Nurse | Named in medication availability and social services follow-up deficiency. |
| Dietary Manager | Dietary Manager | Named in food temperature and meal service timing deficiencies. |
| CNA 22 | Certified Nursing Assistant | Named in observation of water quality. |
| CNA 23 | Certified Nursing Assistant | Named in social services follow-up deficiency. |
| LPN 15 | Licensed Practical Nurse | Named in medication administration oversight finding related to Resident 97. |
| LPN 17 | Licensed Practical Nurse | Named in medication administration oversight finding related to Resident 97. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Dec 14, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report an allegation of neglect and mistreatment of a resident (Resident B) to the appropriate authorities as required by state law.
Findings
The facility failed to report an allegation of neglect and mistreatment involving Resident B to the administrator, Director of Nursing, Executive Director, and the State Survey Agency as required. Interviews revealed that staff were aware of the resident's statements about mistreatment but did not report the incident. The facility's policy requires immediate reporting of abuse allegations, which was not followed.
Complaint Details
This citation relates to Complaint IN00423583. The facility did not report the allegation of mistreatment to the State as required by policy and state law.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities for 1 of 2 residents reviewed for abuse. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents Affected: 1
Date of survey completed: Dec 14, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager 3 | Interviewed regarding Resident B's condition and failure to report abuse allegations | |
| Human Resources Director | Interviewed about Resident B's statements and reporting | |
| Director of Nursing | DON | Interviewed about failure to report abuse allegations |
| Executive Director | ED | Notified about abuse allegations but did not receive report |
Inspection Report
Annual Inspection
Census: 116
Capacity: 116
Deficiencies: 7
Dec 14, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, including investigation of Complaints IN00420944 and IN00423583.
Findings
The facility was found deficient in multiple areas including medication administration oversight, resident and family group response, reporting of alleged violations, provision of medically related social services, pharmacy services, food quality and temperature, and meal/snack timing and availability.
Complaint Details
Complaint IN00423583 had Federal/State deficiencies related to the allegations cited at F609. Complaint IN00402944 had no deficiencies related to the allegations.
Severity Breakdown
SS=E: 5
SS=D: 2
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to ensure appropriate oversight of medication administration during 5 of 25 random observations. | SS=E |
| Failed to act upon resident concerns of food temperatures, taste of food, drinks not being passed at meal times, and medications being left at bedside. | SS=E |
| Failed to report an allegation of neglect and mistreatment to the administrator and other officials in accordance with State law for 1 of 2 residents reviewed for abuse. | SS=D |
| Failed to ensure appropriate social services follow-up and monitoring of residents with hallucinations, concerns, and mood changes for 4 of 5 residents reviewed. | SS=E |
| Failed to ensure accurate documentation in the Controlled Drug Administration Record sheets of administered narcotics for 3 of 56 residents and failed to ensure oral and intravenous antibiotics were available for administration. | SS=D |
| Failed to ensure residents were served meals that conserved flavor, palatability and were at appetizing temperatures. | SS=E |
| Failed to ensure meals were served at designated times and residents were offered a nourishing snack at night. | SS=E |
Report Facts
Survey dates: 2023-12-10 to 2023-12-14
Census Bed Type: 116
Medication administration observations: 5
Resident Council meetings with unresolved concerns: 8
Food Advisory Committee meetings with unresolved concerns: 6
Narcotic medication discrepancies: 3
Missed antibiotic doses: 2
Missed gabapentin doses: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager 3 | Unit Manager | Named in failure to report abuse allegation and medication administration oversight |
| RN 20 | Registered Nurse | Named in medication administration observation deficiency |
| LPN 21 | Licensed Practical Nurse | Named in medication administration observation deficiency |
| Unit Manager 16 | Unit Manager | Named in medication administration and medication left at bedside findings |
| LPN 14 | Licensed Practical Nurse | Named in medication administration observation deficiency |
| LPN 15 | Licensed Practical Nurse | Named in medication administration observation deficiency |
| DON | Director of Nursing | Named in failure to report abuse allegation and medication administration oversight |
| DNS | Director of Nursing Services | Named in staff education and quality assurance monitoring |
| ED | Executive Director | Named in abuse reporting and quality assurance monitoring |
| SSD | Social Services Director | Named in failure to provide adequate social services follow-up |
| CDM | Certified Dietary Manager | Named in food temperature and quality deficiencies |
| Cook 7 | Cook | Named in food temperature monitoring deficiency |
| Cook 8 | Cook | Named in food temperature monitoring deficiency |
| LPN 11 | Licensed Practical Nurse | Named in narcotic medication documentation deficiency |
| RN 12 | Registered Nurse | Named in narcotic medication documentation deficiency |
| RN 19 | Registered Nurse | Named in medication availability and administration oversight |
| CNA 22 | Certified Nursing Assistant | Named in water quality observation |
| CNA 23 | Certified Nursing Assistant | Named in resident emotional support and medication administration observation |
Inspection Report
Follow-Up
Census: 117
Deficiencies: 0
Nov 27, 2023
Visit Reason
This visit was for the Post Survey Revisit (PSR) to the Investigation of Complaint IN00420492 completed on 10/26/23, in conjunction with PSRs to the Investigations of Complaints IN00419726 and IN00420157 completed on 10/24/23.
Findings
Hillcrest Village was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Investigation of Complaint IN00420492. All three complaints were corrected.
Complaint Details
This visit was a follow-up to investigations of three complaints (IN00420492, IN00419726, IN00420157). All complaints were found to be corrected.
Report Facts
Census Bed Type: 117
Census Payor Type: 117
SNF/NF beds: 102
SNF beds: 15
Medicare residents: 14
Medicaid residents: 66
Other residents: 37
Inspection Report
Follow-Up
Census: 117
Deficiencies: 0
Nov 27, 2023
Visit Reason
This visit was for the Post Survey Revisit (PSR) to the Investigation of Complaints IN00419726, IN00420157, and IN00420492 completed in October 2023.
Findings
All three complaints investigated were found to be corrected, and the facility was found to be in compliance with relevant federal and state regulations during this follow-up visit.
Complaint Details
This visit was a follow-up to complaint investigations IN00419726, IN00420157, and IN00420492. All complaints were corrected as of this visit.
Report Facts
Census Bed Type - Total Residents: 117
Census Bed Type - SNF/NF: 102
Census Bed Type - SNF: 15
Census Payor Type - Medicare: 14
Census Payor Type - Medicaid: 66
Census Payor Type - Other: 37
Inspection Report
Complaint Investigation
Census: 121
Capacity: 121
Deficiencies: 2
Oct 26, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00420492 related to federal and state deficiencies concerning medication administration and medication errors.
Findings
The facility failed to ensure medications were administered as ordered for 19 of 20 residents reviewed on the west wing, and failed to prevent significant medication errors related to insulin and anticoagulant administration for 4 of 20 residents reviewed. Documentation of medication administration on 10/24/23 was lacking for multiple residents.
Complaint Details
Complaint IN00420492 was substantiated with federal and state deficiencies cited at tags F755 and F760 related to medication administration and medication errors.
Severity Breakdown
SS=E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure medications were administered as ordered for 19 of 20 residents reviewed on the west wing. | SS=E |
| Failed to prevent significant medication errors related to insulin and anticoagulant administration for 4 of 20 residents reviewed on the west wing. | SS=E |
Report Facts
Residents reviewed for medication administration: 20
Residents with medication administration failures: 19
Residents with significant medication errors: 4
Census: 121
Total capacity: 121
Inspection Report
Complaint Investigation
Deficiencies: 2
Oct 26, 2023
Visit Reason
The inspection was conducted in response to a complaint (IN00420492) regarding medication administration errors at Hillcrest Village nursing home.
Findings
The facility failed to ensure medications were administered as ordered for 19 of 20 residents reviewed on the west wing, with missing documentation of evening medication administration on 10/24/23. Additionally, significant medication errors related to insulin and anticoagulant administration were identified for 4 residents.
Complaint Details
The citation relates to Complaint IN00420492 regarding medication administration errors.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure medications were administered as ordered for 19 of 20 residents reviewed on the west wing, with missing documentation of evening medication administration on 10/24/23. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to prevent significant medication errors related to insulin and anticoagulant administration for 4 residents on the west wing. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for medication administration: 20
Residents affected by medication administration failure: 19
Residents affected by significant medication errors: 4
Medication error rate goal: 5
Inspection Report
Complaint Investigation
Deficiencies: 2
Oct 24, 2023
Visit Reason
The inspection was conducted in response to complaints regarding the facility's failure to ensure safe discharge and adequate supervision during transfers for residents.
Findings
The facility failed to ensure a safe discharge for Resident B, who was discharged home without proper home evaluation or adequate equipment, resulting in the resident needing 24-hour care and returning to the emergency department. Additionally, the facility failed to provide adequate supervision and assistance of two staff members during a transfer for Resident H, resulting in a fall.
Complaint Details
This citation relates to Complaint IN00420157 regarding Resident B's unsafe discharge and Complaint IN00419726 regarding Resident H's inadequate supervision during transfer.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to transfer or discharge a resident without an adequate reason and provide documentation and specific information when a resident is transferred or discharged. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a nursing home area is free from accident hazards and provide adequate supervision to prevent accidents. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Resident height: 71
Resident weight: 363
Residents reviewed for discharge rights: 3
Residents reviewed for accident hazards: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide (CNA) 3 | Transported Resident B home and assisted with transfer | |
| Certified Nurse Aide (CNA) 4 | Transported Resident B home and assisted with transfer | |
| Therapy Manager | Indicated no home evaluation was done for Resident B | |
| Certified Nurse Aide (CNA) 7 | Assisted Resident H during transfer when fall occurred | |
| Certified Nurse Aide (CNA) 5 | Indicated two staff members should be present when sit to stand lift is used | |
| Executive Director | Provided documents related to discharge and stand lift procedures |
Inspection Report
Complaint Investigation
Census: 117
Deficiencies: 2
Oct 23, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00419726 and IN00420157 related to discharge and transfer requirements and accident hazards.
Findings
The facility failed to ensure a safe discharge for Resident B, who was discharged home without a functional hospital bed or home evaluation, resulting in readmission to the hospital. Additionally, the facility failed to provide adequate supervision and assistance of two staff members during a transfer for Resident H, resulting in a fall.
Complaint Details
Complaint IN00419726 cited at F689 related to accident hazards and supervision. Complaint IN00420157 cited at F622 related to transfer and discharge requirements.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure a safe discharge for Resident B, including lack of home evaluation and provision of functional equipment. | SS=D |
| Failed to provide adequate supervision and assistance of two staff members during transfer for Resident H, resulting in a fall. | SS=D |
Report Facts
Census: 117
SNF/NF beds: 102
SNF beds: 15
Medicare residents: 13
Medicaid residents: 67
Other payor residents: 37
Discharges reviewed: 24
Discharges home: 23
Discharges to hospital: 1
Discharges returned to facility: 1
Resident height: 71
Resident weight: 363
Inspection Report
Complaint Investigation
Census: 113
Deficiencies: 0
Oct 11, 2023
Visit Reason
This visit was conducted for the Investigation of Complaint IN00418527.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Complaint Details
Complaint IN00418527 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type Total: 113
Census Bed Type SNF/NF: 98
Census Bed Type SNF: 15
Census Payor Type Medicare: 13
Census Payor Type Medicaid: 68
Census Payor Type Other: 32
Inspection Report
Complaint Investigation
Census: 113
Deficiencies: 0
Sep 25, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00415688.
Findings
The complaint IN00415688 was found to be unsubstantiated due to lack of sufficient evidence. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Complaint Details
Complaint IN00415688 was investigated and found unsubstantiated due to lack of sufficient evidence.
Report Facts
Census: 113
Census SNF/NF beds: 98
Census SNF beds: 15
Census Payor Type Medicare: 14
Census Payor Type Medicaid: 67
Census Payor Type Other: 32
Inspection Report
Complaint Investigation
Census: 112
Deficiencies: 0
Aug 9, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00414230 and IN00414427 at Hillcrest Village.
Findings
No deficiencies related to the allegations in complaints IN00414230 and IN00414427 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Complaint Details
Complaint IN00414230 - No deficiencies related to the allegations are cited. Complaint IN00414427 - No deficiencies related to the allegations are cited.
Report Facts
Census Bed Type - SNF/NF: 97
Census Bed Type - SNF: 15
Census Bed Type - Total: 112
Census Payor Type - Medicare: 10
Census Payor Type - Medicaid: 74
Census Payor Type - Other: 28
Census Payor Type - Total: 112
Inspection Report
Complaint Investigation
Census: 107
Deficiencies: 0
Jun 29, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00407337.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00407337 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 107
SNF/NF beds: 92
SNF beds: 15
Medicare residents: 15
Medicaid residents: 66
Other payor residents: 26
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 19, 2023
Visit Reason
Paper compliance review related to the Investigation of Complaints IN00404248 and IN00406678 completed on April 19, 2023.
Findings
Hillcrest Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review of the complaint investigations.
Complaint Details
The visit was related to complaint investigations IN00404248 and IN00406678 and found the facility in compliance.
Inspection Report
Complaint Investigation
Deficiencies: 2
Apr 19, 2023
Visit Reason
The inspection was conducted based on complaints related to resident rights and medication errors at Hillcrest Village nursing home.
Findings
The facility failed to ensure a resident was notified of a canceled appointment and failed to prevent medication errors for two residents, including incorrect insulin administration and lack of proper notification to physicians and family.
Complaint Details
This Federal tag relates to Complaints IN00404248 and IN00406678.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure a resident was notified when a scheduled appointment was canceled. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents were free from significant medication errors, including incorrect insulin dosing and lack of proper notification. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for resident rights: 3
Residents reviewed for medication errors: 4
Insulin doses administered incorrectly: 2
Medication error rate goal: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN 5 | Licensed Practical Nurse | Administered incorrect dose of insulin to Resident B. |
| LPN 6 | Licensed Practical Nurse | Administered wrong insulin pen to Resident K and notified family member. |
| LPN 7 | Licensed Practical Nurse | Interviewed about the 5 rights of medication administration. |
| LPN 4 | Licensed Practical Nurse | Indicated that physician and family should be notified of medication errors. |
| Social Services Assistant | Reported appointment cancellation issue for Resident F. | |
| Assistant Director of Nursing Services | Canceled Resident F's appointment due to unclear purpose. | |
| Director of Nursing | Provided documents on Resident Rights and medication policies. |
Inspection Report
Complaint Investigation
Census: 115
Capacity: 115
Deficiencies: 2
Apr 17, 2023
Visit Reason
This visit was conducted for the investigation of multiple complaints (IN00403990, IN00404248, IN00405239, IN00406254, and IN00406678) at Hillcrest Village.
Findings
The facility was found deficient in ensuring a resident was notified of a canceled appointment and in preventing significant medication errors for two residents. Two federal/state deficiencies were cited related to complaint allegations, with other complaints having no deficiencies.
Complaint Details
Complaints IN00404248 and IN00406678 were substantiated with deficiencies cited at F760 related to medication errors. Complaints IN00403990, IN00405239, and IN00406254 had no deficiencies related to the allegations.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure a resident was notified when a scheduled appointment was canceled. | SS=D |
| Failed to ensure residents were free of significant medication errors for 2 of 4 residents reviewed. | SS=D |
Report Facts
Census: 115
Total Capacity: 115
Residents reviewed for medication errors: 4
Residents with medication errors: 2
Medicare census: 17
Medicaid census: 74
Other payor census: 24
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mark Bowman | Executive Director | Signed the report |
| LPN 4 | Licensed Practical Nurse | Interviewed regarding notification of appointment cancellations and medication errors |
| LPN 5 | Licensed Practical Nurse | Involved in medication error with Resident B |
| LPN 6 | Licensed Practical Nurse | Involved in medication error with Resident K |
| LPN 7 | Licensed Practical Nurse | Interviewed about medication administration rights |
| Social Services Assistant | Interviewed about appointment scheduling and notification | |
| Director of Nursing | Provided policies and interviewed about resident rights and medication error policies | |
| Assistant Director of Nursing Services | Interviewed about appointment scheduling and notification |
Inspection Report
Follow-Up
Census: 115
Deficiencies: 0
Mar 31, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaints IN00401792 and IN00402410 completed on 3/10/23, and in conjunction with the PSR to the Investigation of Complaint IN00399029 completed on 2/3/23.
Findings
All three complaints (IN00401792, IN00402410, and IN00399029) were found to be corrected. The facility was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 in regard to these complaints.
Complaint Details
This visit was related to complaint investigations IN00401792, IN00402410, and IN00399029. All complaints were corrected as of this visit.
Report Facts
Census Bed Type: 115
Census Payor Type - Medicare: 16
Census Payor Type - Medicaid: 75
Census Payor Type - Other: 24
Census Bed Type - SNF/NF: 100
Census Bed Type - SNF: 15
Inspection Report
Follow-Up
Census: 115
Deficiencies: 0
Mar 31, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00399029 completed on 2/3/23, conducted in conjunction with PSRs to Investigations of Complaints IN00401792 and IN00402410 completed on 3/10/23.
Findings
Hillcrest Village was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 in regard to the PSRs for the investigations of the complaints. All three complaints were corrected.
Complaint Details
This visit was related to complaint investigations IN00399029, IN00401792, and IN00402410. All complaints were found to be corrected.
Report Facts
Census Bed Type - SNF/NF: 100
Census Bed Type - SNF: 15
Census Bed Type - Total: 115
Census Payor Type - Medicare: 16
Census Payor Type - Medicaid: 75
Census Payor Type - Other: 24
Census Payor Type - Total: 115
Inspection Report
Complaint Investigation
Deficiencies: 2
Mar 10, 2023
Visit Reason
The inspection was conducted as a complaint investigation related to allegations of improper discharge and failure to address abnormal laboratory results for residents at the facility.
Findings
The facility failed to ensure a resident discharged to the hospital was allowed to return, and failed to address abnormal lab results in a timely manner for another resident. Documentation and communication deficiencies were noted regarding resident behaviors and hospital discharge procedures.
Complaint Details
This Federal tag relates to Complaint IN00401792 for the discharge/return issue and Complaint IN00402410 for the laboratory services issue.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure a resident discharged to the hospital was allowed to return. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure a resident's abnormal labs were addressed in a timely manner. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed: 3
Sodium level: 157
Potassium level: 3.1
Chloride level: 118
Sodium level: 163
Potassium level: 3.2
Chloride level: 122
IV Sodium Chloride solution delivery time: 5.25
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Executive Director | Interviewed regarding resident discharge and psychiatric evaluation |
| Director of Nursing | Director of Nursing | Provided facility policies and documentation related to behavior management and hospital discharge/transfer |
| Nurse Practitioner | Nurse Practitioner | Reviewed lab results and provided orders for IV fluids; interviewed regarding lab notification |
Inspection Report
Complaint Investigation
Census: 120
Capacity: 120
Deficiencies: 2
Mar 8, 2023
Visit Reason
This visit was conducted for the investigation of three complaints (IN00401792, IN00402393, and IN00402410) related to the facility's compliance with federal and state regulations.
Findings
The facility was found deficient in two complaints: one related to transfer and discharge requirements where a resident discharged to the hospital was not allowed to return, and another related to laboratory services where abnormal lab results were not addressed timely. One complaint had no deficiencies cited.
Complaint Details
Complaint IN00401792 was substantiated with deficiencies cited at F622 related to transfer and discharge requirements. Complaint IN00402393 had no deficiencies related to the allegations. Complaint IN00402410 was substantiated with deficiencies cited at F773 related to lab services and notification of results.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure a resident discharged to the hospital was allowed to return to the facility. | SS=D |
| Failed to ensure a resident's abnormal lab results were addressed in a timely manner. | SS=D |
Report Facts
Census: 120
Total Capacity: 120
Hospital transfers reviewed: 33
Residents remaining hospitalized: 6
Residents expired: 1
Lab sodium level: 157
Lab potassium level: 3.1
Lab chloride level: 118
Critical sodium level: 163
Critical potassium level: 3.2
Critical chloride level: 122
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mark Bowman | Executive Director | Interviewed regarding resident discharge and hospital bed availability |
Inspection Report
Complaint Investigation
Deficiencies: 1
Feb 3, 2023
Visit Reason
The inspection was conducted in response to a complaint (IN00399029) regarding medication administration documentation for a resident.
Findings
The facility failed to ensure that the medical record for Resident E accurately reflected the administration of antibiotics, with missing documentation for doses of Vancomycin and Ceftazidime on specific dates in January 2023.
Complaint Details
This Federal tag relates to Complaint IN00399029.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure a resident's record accurately reflected the administration of antibiotics for 1 of 3 residents reviewed for medication administration. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Medication doses missed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse 3 | Indicated medications should be signed out on the medication administration record when administered. | |
| Director of Nursing | Provided a current copy of the document titled General Dose Preparation and Medication Administration dated 1/1/13. |
Inspection Report
Complaint Investigation
Census: 116
Capacity: 116
Deficiencies: 1
Feb 2, 2023
Visit Reason
This visit was conducted for the investigation of two complaints, IN00396870 and IN00399029. Complaint IN00396870 was substantiated with no deficiencies cited, while Complaint IN00399029 was substantiated with a federal/state deficiency cited at F842.
Findings
The facility failed to ensure that a resident's medical record accurately reflected the administration of antibiotics for 1 of 3 residents reviewed. Specifically, medication administration records lacked documentation of certain antibiotic doses given to Resident E. The facility provided a plan of correction including staff education, audits, and monitoring to prevent recurrence.
Complaint Details
Complaint IN00396870 was substantiated with no deficiencies cited. Complaint IN00399029 was substantiated with a federal/state deficiency cited at F842 related to resident records and identifiable information.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure resident's medical record accurately reflected administration of antibiotics for 1 of 3 residents reviewed. | SS=D |
Report Facts
Census: 116
Total Capacity: 116
Medicare Census: 10
Medicaid Census: 74
Other Payor Census: 32
Date of Compliance: Feb 10, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mark Bowman | Executive Director | Signed the report |
| Director of Nursing | Provided document titled 'General Dose Preparation and Medication Administration' and involved in corrective action plan | |
| RN 3 | Interviewed regarding medication administration documentation | |
| Clinical Education Coordinator | Performed one-on-one in-service training related to the deficient practice |
Inspection Report
Re-Inspection
Census: 118
Capacity: 149
Deficiencies: 0
Jan 20, 2023
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 12/13/22 was performed to verify compliance with life safety and licensure requirements.
Findings
Hillcrest Village was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101 Life Safety Code. The facility is fully sprinklered with a fire alarm system and smoke detection throughout.
Report Facts
Facility capacity: 149
Census: 118
Inspection Report
Re-Inspection
Census: 117
Deficiencies: 0
Jan 19, 2023
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on 11/18/22.
Findings
Hillcrest Village was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey.
Report Facts
Census SNF: 15
Census NF: 112
Total Census: 117
Census Medicare: 15
Census Medicaid: 82
Census Other: 20
Inspection Report
Life Safety
Census: 113
Capacity: 149
Deficiencies: 2
Dec 13, 2022
Visit Reason
The visit was conducted as a Life Safety Code Recertification and State Licensure Survey by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The facility was found not in compliance with Life Safety Code requirements related to egress door locking arrangements and smoking regulations. Specifically, 3 of 11 outside exits had locking codes not readily accessible to all residents, and cigarette butts were improperly disposed of in one resident smoking area.
Severity Breakdown
SS=E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to ensure the means of egress through 3 of 11 outside exits was readily accessible for residents without a clinical diagnosis requiring specialized security measures; doors required a keypad code not known to all. | SS=E |
| Failed to ensure cigarette butts were properly disposed of at 1 of 2 resident smoking areas; large trash can contained paper trash mixed with hundreds of cigarette butts. | SS=E |
Report Facts
Certified beds: 149
Census: 113
Number of outside exits with deficient egress door locking: 3
Number of resident smoking areas observed: 2
Number of residents potentially affected by egress door deficiency: 28
Number of residents potentially affected by smoking regulation deficiency: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mark Bowman | Executive Director | Named in relation to review of findings during exit conference |
| Maintenance Director | Involved in observations, interviews, and corrective actions related to egress door and smoking deficiencies | |
| Senior Maintenance Supervisor | Involved in observations and exit conference related to deficiencies |
Inspection Report
Annual Inspection
Deficiencies: 5
Nov 18, 2022
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for Hillcrest Village nursing home.
Findings
The facility was found deficient in several areas including failure to provide appropriate bed and mattress size for a tall resident, failure to honor resident meal preferences, incomplete documentation of insulin administration, inadequate pressure ulcer care and prevention, failure to implement infection control practices including proper use of PPE, and failure to follow isolation precautions for a resident with MRSA.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to provide a bed and mattress that accommodated the height of Resident 309. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to honor Resident 35's meal preferences and choices, resulting in repeated serving of disliked foods. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure appropriate documentation of blood sugar levels and insulin administration for Resident 66. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to initiate or implement interventions to prevent and treat pressure ulcers for Residents 39 and 310. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to implement infection prevention and control program properly, including failure to use PPE correctly and failure to maintain isolation precautions for MRSA. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Resident beds observed: 108
Resident reviewed for food choices: 3
Resident reviewed for quality of care: 5
Residents reviewed for pressure ulcers: 11
Staff observed for infection prevention: 9
County positivity rate: 21.56
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN 14 | Registered Nurse | Interviewed regarding Resident 35's dietary dislikes and insulin administration |
| Dietary Manager | Interviewed regarding resident meal preferences and meal ticket system | |
| Dietary Assistant | Interviewed regarding meal ticket errors and serving of disliked foods | |
| Director of Nursing | Director of Nursing | Provided policies and interviewed regarding medication administration and infection control |
| Wound Nurse 3 | Provided wound care and interviewed regarding pressure ulcer care | |
| Wound Nurse 5 | Assisted Wound NP and interviewed regarding infection control and wound care | |
| Wound NP 4 | Nurse Practitioner | Conducted wound assessments and interviewed regarding infection control and wound care |
| RN 8 | Assisted with wound dressing and interviewed regarding missing dressing | |
| CNA 9 | Certified Nurse Aide | Observed and reported missing dressing and resident compliance with offloading |
| CNA 13 | Certified Nurse Aide | Interviewed regarding turning and repositioning of Resident 310 |
| ADON | Assistant Director of Nursing | Provided wound care and interviewed regarding pressure ulcer status |
| LPN 17 | Licensed Practical Nurse | Provided wound care for Resident 310 |
| Infection Preventionist | Interviewed regarding infection control policies and county positivity rate |
Inspection Report
Annual Inspection
Census: 115
Capacity: 115
Deficiencies: 5
Nov 14, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from November 14 to 18, 2022.
Findings
The facility was found deficient in multiple areas including failure to provide appropriate bed accommodations for a tall resident, honoring resident meal preferences, proper documentation and administration of insulin for a diabetic resident, prevention and treatment of pressure ulcers, and adherence to infection control practices including proper use of PPE.
Severity Breakdown
SS=D: 4
SS=E: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Facility failed to provide a bed and mattress that could accommodate the height of a resident comfortably. | SS=D |
| Facility failed to ensure resident preferences and choices for meal service were honored. | SS=D |
| Facility failed to ensure appropriate documentation of blood sugar levels and administration of insulin for a resident with diabetes. | SS=D |
| Facility failed to ensure interventions were initiated or implemented and failed to prevent the development of two Stage 2 pressure ulcers for 2 residents. | SS=D |
| Facility failed to ensure infection control practices were followed related to proper use of personal protective equipment (PPE) for 5 staff members. | SS=E |
Report Facts
Census Bed Type: 115
Census Payor Type: 115
County COVID Positivity Rate: 21.56
Deficiency Completion Date: Dec 15, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mark Bowman | Executive Director | Signed the report |
| RN 14 | Mentioned in relation to meal preference deficiency and insulin administration | |
| Wound Nurse 3 | Involved in wound care and observations related to pressure ulcers | |
| Wound Nurse 5 | Assisted Nurse Practitioner during wound assessment | |
| Nurse Practitioner 4 | Conducted wound assessments and noted PPE non-compliance | |
| DON | Director of Nursing | Provided interviews regarding wound care and infection control |
| CNA 9 | Certified Nurse Aide | Observed dressing off resident's heel and reported to nurse |
| CNA 13 | Certified Nurse Aide | Responsible for care of Resident 310 and admitted to not turning resident timely |
| Dietary Cook 11 | Observed with improper mask use during food service | |
| Dietary Aide 12 | Observed with improper mask use during food service | |
| Dietary Cook 12 | Observed with improper mask use during food preparation | |
| Dietary Aide 13 | Observed with improper mask use during food preparation | |
| Dishwashing Aide 18 | Observed with mask below nose and chin while washing dishes |
Inspection Report
Complaint Investigation
Census: 116
Deficiencies: 0
Aug 29, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00382658.
Findings
The complaint was found to be unsubstantiated due to lack of sufficient evidence. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the complaint investigation.
Complaint Details
Complaint IN00382658 was investigated and found unsubstantiated due to lack of sufficient evidence.
Report Facts
Census: 116
SNF/NF beds: 101
SNF beds: 15
Medicare residents: 13
Medicaid residents: 67
Other payor residents: 36
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