Inspection Reports for
Hillcrest Village

This citation relates to Complaint IN00456231.

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 IN00456231 was substantiated with federal/state deficiencies cited at F684 related to medication administration errors.

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.

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.

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.

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.

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.

This Citation relates to Complaint IN00444619.

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 IN00444619 was substantiated with federal/state deficiencies cited at F554, F580, F684, and F842. Complaints IN00445272 and IN00446007 were not substantiated with deficiencies.

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 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.

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.

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.

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.

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.

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.

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.

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.

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.

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 IN00423583 had Federal/State deficiencies related to the allegations cited at F609. Complaint IN00402944 had no deficiencies related to the allegations.

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 IN00420492 was substantiated with federal and state deficiencies cited at tags F755 and F760 related to medication administration and medication errors.

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.

The citation relates to Complaint IN00420492 regarding medication administration errors.

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.

This citation relates to Complaint IN00420157 regarding Resident B's unsafe discharge and Complaint IN00419726 regarding Resident H's inadequate supervision during transfer.

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 IN00419726 cited at F689 related to accident hazards and supervision. Complaint IN00420157 cited at F622 related to transfer and discharge requirements.

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.

This Federal tag relates to Complaints IN00404248 and IN00406678.

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.

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.

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.

This Federal tag relates to Complaint IN00401792 for the discharge/return issue and Complaint IN00402410 for the laboratory services issue.

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 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.

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.

This Federal tag relates to Complaint IN00399029.

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 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.

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.

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.

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.

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.