Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hillcrest Home during CMS and state inspections, most recent first.
A dietary aide was observed placing meal tickets in her mouth, retrieving one from the floor with her bare hand, and then preparing and serving drinks to a resident without performing hand hygiene. The aide subsequently delivered additional meal trays without washing her hands, despite having completed required food handler training. The dietary supervisor confirmed these actions did not meet infection control standards.
The facility did not have a licensed Administrator overseeing daily operations, as required by policy and regulation. Over several days of observation, no Administrator was present or had a posted license. The DON confirmed acting in the Administrator role since the position became vacant, with oversight from the County Administrator. This affected all residents in the facility.
The facility did not notify the Ombudsman of hospital discharges and transfers for several Private Pay residents, as required. The omission occurred because the report sent to the Ombudsman excluded Private Pay residents, and staff were unaware that these residents should be included.
A wound nurse brought a treatment cart containing wound care supplies for multiple residents into a resident's room during pressure ulcer care, contrary to facility policy requiring the cart to remain outside. This practice, observed and confirmed by staff, increased the risk of cross-contamination among residents receiving wound care.
A resident who was cognitively intact was listed as DNR in the POLST and care plan, but there was no documentation of any discussion with the resident about code status. When interviewed, the resident stated a preference for full resuscitation, indicating the facility did not ensure advance directives reflected the resident's wishes.
Two residents experienced falls due to improper transfer techniques and lack of supervision, with one resident not having safety straps fastened during a mechanical lift transfer and another falling from a wheelchair without brakes locked. Both incidents were not thoroughly investigated or monitored according to policy, with missing documentation, incomplete assessments, and delayed interdisciplinary review.
The facility posted its daily nurse staffing information in a format that was unclear and did not include the facility's name. The posted sheet showed calculations for licensed nurse and direct care hours, with actual RN, LPN, and CNA numbers written off to the side. The DON confirmed this was the standard posting method used for some time.
A resident with severe cognitive impairment and on anticoagulant medication experienced an unwitnessed fall. The facility delayed notifying the physician by five hours and failed to mention the anticoagulant use, which is crucial due to the increased risk of bleeding. Staff interviews revealed inconsistencies in the notification process, and no policy for notification of changes was provided.
The facility quarantined six residents without clear reasoning, causing one resident to become very upset. Staff members were confused and frustrated, noting that the symptoms were consistent with seasonal allergic rhinitis. The Infection Preventionist later admitted to overreacting and acknowledged that the resident could have been allowed to leave his room with a mask on.
The facility failed to implement its Antibiotic Stewardship Program, as the Infection Preventionist stated that no protocols are in place to review clinical signs and symptoms or lab reports before administering antibiotics. Instead, staff call the doctor for an antibiotic order if they believe one is needed, affecting all 62 residents.
The facility failed to ensure that call lights were equipped to communicate directly to staff, leading to long wait times for residents needing assistance. Staff were not always aware of activated call lights, and the system's sound alerts were often turned down or not functioning properly. Interviews and observations confirmed that the new system hindered prompt responses, especially during busy times.
A resident with impaired cognition and a history of falls experienced a fall due to the absence of a non-slip mat in her wheelchair, despite it being a documented fall prevention intervention in her care plan. The facility's failure to ensure the mat was in place led to the deficiency.
A facility failed to ensure that PRN psychotropic medications were not prescribed for more than 14 days for a resident. Despite the facility's policy, a resident's PRN order for Lorazepam was extended for six months without proper justification, and staff interviews revealed that this practice was common, leading to the deficiency.
A CNA, inadequately trained on a specific facility van, failed to yield at an intersection while transporting a resident from the hospital, resulting in a collision with two other vehicles. Both the CNA and the resident were evaluated at the ER with no injuries reported. The CNA received a traffic citation for failure to yield.
Failure to Follow Infection Control Practices During Meal Service
Penalty
Summary
A deficiency was identified when a dietary aide was observed engaging in improper infection control practices while serving meals in the dining room. Specifically, the aide placed two meal tickets in her mouth, dropped one on the floor, picked it up with her bare hand, and then proceeded to pour apple juice and prepare hot chocolate for a resident without performing hand hygiene. The aide then delivered the drinks and meal trays to residents without washing her hands. The dietary supervisor confirmed that the aide had completed the required food handler training and acknowledged that the actions taken were not in accordance with proper infection control procedures.
Failure to Employ Licensed Administrator to Oversee Facility Operations
Penalty
Summary
The facility's governing body failed to employ a licensed Administrator to oversee and manage daily operations, as required by policy and regulation. Review of the facility's census roster and matrix confirmed that 46 residents were present in the facility. The Administrator's job description specifies that the Administrator must hold a current, unencumbered nursing facility Administrator's license and is responsible for supervising all departments and ensuring compliance with applicable laws and regulations. Observations conducted over several days revealed that there was no licensed Administrator present in the building, nor was an Administrator's license posted. The Director of Nursing confirmed that the facility had not had an Administrator since a specific date and that she was acting in that capacity, with the County Administrator serving as a resource. The absence of a licensed Administrator was acknowledged by facility leadership.
Failure to Notify Ombudsman of Hospital Transfers for Private Pay Residents
Penalty
Summary
The facility failed to notify the Ombudsman of all hospital discharges and transfers for four residents who were hospitalized, as required. Review of the Hospital Tracking Portal showed that these residents were transferred to the hospital, but their information was not included in the facility's Admit Discharge report for the relevant period. An interview with the Business Office Manager revealed that the report sent to the Ombudsman excluded residents with Private Pay as their primary payer source, due to a lack of awareness that these residents should also be included. The Daily Census confirmed that the affected residents were Private Pay at the time of their hospital transfers.
Failure to Prevent Cross-Contamination During Wound Care
Penalty
Summary
The facility failed to maintain a contamination-free environment during wound care for a resident receiving treatment for a pressure ulcer. Specifically, the wound nurse brought the facility's treatment cart, which contained wound care supplies for multiple residents, into the resident's room and placed supplies on top of the cart before performing wound care. This action was observed during wound care for a resident with physician orders for daily cleansing and dressing of a sacral pressure ulcer. The facility's policy for clean dressing technique specifies that the treatment cart should not be brought into the resident's room and that a clean field should be established using clean linen or a plastic field, not on the treatment cart itself. Interviews with facility staff confirmed that the treatment cart is intended to remain outside the resident's room, and the infection control coordinator verified that bringing the cart into the room is against facility policy. The wound care supplies for all residents receiving wound care were stored in the same treatment cart, which was moved from room to room, increasing the risk of cross-contamination. This practice was observed and acknowledged by staff, and the facility's own policy documentation was provided to confirm the correct procedure.
Failure to Honor Resident's Advance Directive Preferences
Penalty
Summary
The facility failed to ensure that advance directives accurately reflected a resident's current preferences regarding life-sustaining treatment. According to the facility's policy, the POLST (Practitioner Order for Life-Sustaining Treatment) form should be completed or reviewed with the resident and/or their legal representative and updated periodically to reflect the resident's wishes. For one resident, the POLST form and care plan documented a Do Not Resuscitate (DNR) status, but there was no evidence in the clinical record that any discussion had occurred with the resident regarding their code status preferences. During an interview, the resident, who was documented as cognitively intact on both admission and quarterly MDS assessments, stated that no one had asked about their wishes in the event of cardiac or respiratory arrest and clearly expressed a desire for full resuscitation efforts. The Social Service Director reported that code status is typically discussed with residents or their representatives, but in this case, decisions were made by the state guardian without documented input from the resident, despite the resident's capacity to make such decisions.
Failure to Ensure Safe Transfers and Adequate Post-Fall Monitoring
Penalty
Summary
The facility failed to ensure safe transfer practices and adequate post-fall monitoring for two residents, resulting in deficiencies related to accident prevention and investigation. One resident, identified as being at moderate risk for falls, experienced a fall during a transfer from the toilet to a wheelchair using a mechanical lift. The CNA responsible did not position the resident's feet correctly on the lift platform, failed to fasten the safety strap behind the resident's legs, and did not listen to the resident's concerns about foot positioning. This improper technique led to the resident's foot slipping and a subsequent fall to the floor. The care plan required these safety measures, but they were not followed during the incident. Another resident, with a history of falls and multiple risk factors such as impaired balance and weakness, fell while attempting to hang up a phone from her wheelchair, which did not have the brakes locked. The resident sustained a deep laceration to her right elbow, which was not appropriately assessed or monitored according to facility policy and physician orders. The wound was not identified by therapy staff who witnessed the fall until the following day, and there was a lack of documentation of vital signs and wound assessments for the required periods post-fall. The interdisciplinary team did not review the incident until nine days after the fall, and key witness interviews were missing from the investigation. The facility's fall prevention policy required thorough investigation, monitoring, and documentation following any fall, including witness statements, post-fall huddles, and ongoing resident assessments. In both cases, these procedures were not fully implemented, resulting in incomplete investigations and insufficient monitoring of the residents' conditions after their accidents. The failures included not following care plan interventions, not conducting timely and complete assessments, and not ensuring all relevant staff were interviewed as part of the investigation.
Deficient Nurse Staffing Information Posting
Penalty
Summary
The facility failed to ensure that its posted nurse staffing information was presented in a clear format and included the name of the facility. On the date of observation, the Minimum Daily Staffing Calculations sheet was posted in the front hallway, but it did not display the facility's name and was not easily readable. The posted sheet documented calculations for total licensed nurses and non-nurse staffing hours, with the actual numbers of RNs, LPNs, and CNAs written off to the side. The Director of Nursing confirmed that this calculation sheet is the one used for posting and has been used for an extended period. At the time of the survey, 46 residents resided in the facility.
Failure to Timely Notify Physician of Resident Fall and Anticoagulant Use
Penalty
Summary
The facility failed to notify a physician in a timely manner following an unwitnessed fall of a resident, who was on anticoagulant medication. The resident, identified as R2, had severe cognitive impairment and was taking Eliquis for chronic atrial fibrillation. After the fall, the resident was found on the floor, and although vital signs were within normal limits and no injuries were noted, the physician was notified five hours later via fax. The notification did not include the critical information that the resident was on anticoagulant medication, which is essential due to the increased risk of bleeding. Interviews with facility staff revealed inconsistencies in the notification process. The Assistant Director of Nursing stated that the physician should have been notified immediately and informed about the anticoagulant medication. The LPN mentioned that she would typically call the physician rather than fax them, and the Medical Director expressed a preference for phone calls in such situations. The facility did not provide a policy for notification of changes, indicating a lack of clear guidelines for staff to follow in these situations.
Unnecessary Quarantine of Residents
Penalty
Summary
The facility quarantined six residents to remain in their rooms without clear reasoning, causing one resident to become very upset and anxious. The facility's policy for outbreak investigation requires measures to be instituted when there is an incidence of infections above what would normally be expected. However, upon entry to the facility, no staff members were wearing masks, and the receptionist stated there were no known outbreaks or illnesses. Later, staff members were observed passing out surgical masks and instructing others to mask up due to an outbreak status. The Infection Preventionist decided to implement masking because of an uptick in respiratory issues but did not indicate that residents were being asked to remain in their rooms at that time. Multiple staff members expressed confusion and frustration over the decision to quarantine residents, noting that the symptoms were consistent with seasonal allergic rhinitis rather than an outbreak of infectious disease. One resident, in particular, was very upset about being confined to his room, expressing his frustration to staff members and questioning the inconsistency of the quarantine measures. The resident had been experiencing respiratory symptoms for about a week but was starting to feel better. Despite this, he was kept in his room unnecessarily for several meals. The Infection Preventionist later admitted to overreacting and acknowledged that the resident could have been allowed to leave his room with a mask on. The lack of clear communication and investigation into the residents' symptoms before implementing the quarantine measures led to unnecessary confinement and distress for the affected residents.
Failure to Implement Antibiotic Stewardship Program
Penalty
Summary
The facility failed to implement its Antibiotic Stewardship Program, which has the potential to affect all 62 residents. The facility's policy requires the Infection Preventionist to encourage and educate staff to use McGeer's definitions of infections and to monitor vital signs, intake and output, lung sounds, and other signs of infection. However, the Infection Preventionist stated that the facility does not implement any protocols to review clinical signs and symptoms or laboratory reports before administering antibiotics. Instead, they simply call the doctor to get an antibiotic order if they believe one is needed. This lack of protocol adherence was confirmed through interviews and record reviews.
Failure to Ensure Effective Call Light System
Penalty
Summary
The facility failed to ensure that call lights were equipped to communicate directly to staff, affecting the response time to residents' needs. The Software User Guide indicated that the nurse call system was designed for Independent and Assisted Living facilities, requiring staff to be at their computers to receive alerts. Multiple residents reported long wait times for assistance, with one resident stating they had waited up to 70 minutes. Observations confirmed that staff were not always aware of activated call lights, and the system's sound alerts were often turned down or not functioning properly. Additionally, the system required frequent restarts, and staff had to manually check computers to identify alarms, leading to delays in response times. Interviews with staff revealed that the new system hindered their ability to respond promptly to call lights, especially during busy times. Physical and occupational therapists noted that they were no longer alerted to nurse calls, further impacting response times. Observations showed that call lights remained active for extended periods without staff intervention, and the system's volume was often turned down due to its annoying sound. The facility's administrator acknowledged that in case of power or Wi-Fi loss, alternative measures like bells and 15-minute checks were implemented, but these were not sufficient to address the ongoing issues with the call light system.
Failure to Implement Fall Interventions
Penalty
Summary
The facility failed to ensure fall interventions were implemented to prevent further falls for a resident reviewed for falls. The resident, who was nonverbal and had impaired cognition, was found lying in a low bed with a fall mat next to her bed. The resident's care plan indicated a risk for falls due to impaired balance, poor coordination, and poor safety awareness. Despite this, the resident experienced a fall when she slid out of her chair in the dining room, and it was noted that a non-slip mat, which was a previously implemented fall prevention intervention, was not in place in her wheelchair at the time of the fall. The facility's Fall Reduction Program policy required that all residents receive adequate supervision, assistance, and assistive devices to prevent falls. However, after the investigation of the resident's fall, it was confirmed that the non-slip mat was missing from the resident's wheelchair, and staff had to be re-educated to ensure the mat was in place. This lapse in following the care plan and ensuring the necessary fall prevention measures were in place led to the deficiency identified by the surveyors.
Failure to Limit PRN Psychotropic Medication Orders
Penalty
Summary
The facility failed to ensure that psychotropic medications given on an as-needed (PRN) basis were not prescribed for more than 14 days for one resident. The facility's policy requires that residents with dementia receive appropriate treatment to maintain their highest practicable well-being. However, the Physician Order Sheet for the resident documented a prescription for Lorazepam 0.5 mg every eight hours for anxiety, which was extended beyond the 14-day limit without proper justification. Observations of the resident showed no behaviors that would necessitate the continued use of the medication, and staff interviews indicated that the resident's behaviors were typically related to urinary tract infections rather than ongoing anxiety or aggression. The Medication Administration Records indicated that the last administration of Ativan on a PRN basis was several months prior, yet the PRN order was extended for six months without a documented stop date. Staff interviews confirmed that it was not the facility's policy to extend PRN psychotropic orders beyond 14 days, but it was a common practice. This discrepancy between policy and practice led to the deficiency, as the facility did not adhere to its own guidelines for the administration of psychotropic medications on a PRN basis.
Failure to Operate Facility Van Safely
Penalty
Summary
Facility staff failed to operate the facility van safely, resulting in an accident involving a resident. The incident occurred when a Certified Nursing Assistant (CNA) was instructed to pick up a resident from the hospital using a facility van. The CNA, who had not been adequately trained on the specific van, struggled with its operation and was under pressure due to the weather conditions and the urgency of the task. The CNA failed to yield at an intersection, causing a collision with two other vehicles. Both the CNA and the resident were taken to the emergency room for evaluation, with no injuries reported. The facility's policy on transportation requires employees to use facility vehicles for transporting residents and mandates immediate reporting of any accidents. The CNA involved had been employed at the facility for several years and had some prior training in transportation but was not familiar with the specific van used on the day of the incident. The CNA expressed dissatisfaction with the situation, citing a lack of proper training and the stressful circumstances under which the task was assigned. The police report confirmed that the CNA failed to yield at the intersection, leading to the accident. Witnesses and the CNA's own account corroborated the sequence of events. The CNA was issued a traffic citation for failure to yield. The incident highlights a lapse in ensuring that staff operating facility vehicles are adequately trained and familiar with the specific equipment they are required to use, as well as the importance of following designated routes to avoid hazardous intersections.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Geneseo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hammond-henry District Hsp | 0.3 mi | ★★★★★ | 3 | 2 |
| Allure Of Geneseo | 1.1 mi | ★★★★★ | 6 | 0 |
| Avenues At Quad Cities | 13.4 mi | ★★★★★ | 0 | 0 |
| Silvis Center For Nursing Rehab & Care | 13.6 mi | ★★★★★ | 6 | 0 |
| Celebrate Sr Living Of Moline | 14.4 mi | ★★★★★ | 1 | 0 |
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