Above average — CMS composite of the measures below.
The next survey window likely opens around November 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 Nursing And Rehabilitation Community during CMS and state inspections, most recent first.
Medication administration and documentation errors occurred for multiple residents. An RN administered part of a medication pass without immediately documenting the doses, then completed the remaining medications later. Several residents with diabetes received insulin when blood sugars were below the ordered hold parameters, and another resident received midodrine when systolic BP was above the ordered limit. The EMR contained no documentation supporting the exceptions, and the DON confirmed the errors.
Food Storage and Sanitation Deficiencies: Debris was observed in the ice scoop holder, a sprinkler water line was located directly above dry goods, and a refrigerator used for residents' personal food contained undated salsa with mold growth and water on the top shelf. The DM stated dietary staff was not responsible for dating residents' food.
Infection prevention and control was deficient because the facility did not have an active plan to reduce the risk of legionella and other OPPP. The MS stated that a room’s shower water lines had been non-operational for over a year and were not being flushed, and observation showed the shower lacked a faucet handle and did not appear operable at the wall. The water management document stated that maintenance runs faucets and flushes toilets during monthly rounds.
A medication pass error occurred when an RN administered incorrect doses of vitamin C, potassium chloride, and vitamin D3 to a resident during the morning med pass. The resident’s order summary showed higher ordered doses than what was given, and the facility’s medication error rate was 8.33% based on 3 errors out of 36 opportunities.
A resident with advanced cognitive impairment and physical limitations suffered a second-degree burn after being served hot chocolate in bed without a lid, despite being identified as high risk for hot liquid injuries. The facility failed to follow its own policy requiring quarterly hot food/liquid assessments, did not document beverage temperatures at the time of the incident, and did not ensure the resident consumed hot liquids only while seated at a table.
Two residents in an LTC facility did not receive care planned interventions to prevent skin breakdown. One resident, with a history of stroke and hand contractures, was observed without her prescribed hand splints, and her TV was off despite care plan instructions. Another resident, at risk for skin breakdown, was not wearing foam boots as required. The DON confirmed that care plans should be followed, highlighting a failure in implementing necessary interventions.
The facility failed to conduct comprehensive assessments and properly document medication administration for two residents. One resident with multiple health issues experienced a decline in condition without proper assessment or provider notification, leading to a hospital transfer for severe sepsis. Another resident's controlled medication was not properly documented, with discrepancies found during a narcotic count. The facility did not adhere to its policies on vital signs assessment and controlled substances handling.
A medication cart in the North Hall was left unlocked and unattended, observed by a surveyor. RN B was seen leaving the cart unsecured, and despite being questioned, denied the oversight. Staff and facility policies emphasize the importance of securing medication carts, which was not followed in this case.
A facility failed to implement transmission-based precautions for a resident suspected of having C. diff, resulting in potential cross-contamination. The resident, with a history of multiple health issues, was not placed in contact precautions despite ongoing diarrhea and pending lab results. Miscommunication led to incorrect signage, and staff entered the room without PPE. The DON acknowledged the oversight and planned to consult with health authorities.
The facility failed to provide adequate supervision to prevent falls for three residents, resulting in one resident sustaining a hip fracture and the potential for serious injuries to the other two residents. The residents had histories of unsafe behaviors and required assistance, but there were no structured supervision or documentation measures in place. Staff reported being understaffed and unable to adequately supervise residents with dementia who were awake at night.
The facility failed to develop and implement a meaningful activities program for four residents, resulting in them sitting unsupervised and experiencing boredom without the option for diversional activities. Observations revealed that residents with significant medical diagnoses and cognitive impairments were left without activities or consistent supervision, and their care plans did not include necessary interventions. The facility did not have an activity director or aide on staff, and there was no documentation of an activities program for residents with cognitive impairments.
Medication Administration and Documentation Errors
Penalty
Summary
The facility failed to follow professional standards of nursing practice for medication administration for 5 of 12 residents reviewed. For one resident, an RN administered 10 of 22 scheduled morning medications and left the room without stating that he would return with additional medications or that any medications were unavailable. When the MAR was reviewed shortly afterward, those 10 medications had not yet been documented as administered, and the RN later stated that medications were to be documented immediately after administration and that he returned later to give the remaining medications before finalizing the EMAR. Several residents had medications administered outside of ordered parameters without documentation to support the exceptions. One resident with diabetes had Humalog ordered three times daily with breakfast, lunch, and dinner, to be held for blood sugar less than 120, yet the medication was given on multiple occasions when blood sugar readings were 115, 73, 102, and 111. Another resident with diastolic congestive heart failure had midodrine ordered three times daily before meals, to be held if systolic blood pressure was greater than 140, yet the morning dose was given when blood pressure was 157/79 and again when it was 157/77. Two additional residents with diabetes had insulin orders to be held when blood sugar was below 120, but their insulin was administered when blood sugars were 90, 119, 93, 100, 107, 83, 91, 111, 112, 109, and 105. Review of the electronic medical record showed no documentation that the medications were held or documentation supporting administration outside of the ordered parameters. The DON confirmed the medication and documentation errors and stated that a licensed nurse had incorrectly documented medications as held on multiple dates.
Food Storage and Sanitation Deficiencies
Penalty
Summary
Food service areas were found to be maintained below professional standards during observation and record review. On 12/02/2025 at 10:05 AM, debris was observed collected in the bottom of the ice scoop holder mounted on the wall by the ice machine. The report cited 2022 FDA Food Code section 4-601.11, which requires equipment food-contact surfaces, utensils, and nonfood-contact surfaces to be kept clean and free of soil and debris. Additional food storage concerns were identified in the dry storage room and in the refrigerator used for residents' personal food. At 10:21 AM, a water line at ceiling level was observed directly over dried good products on shelving, and the Maintenance Supervisor confirmed the line was a sprinkler system water line. At 10:28 AM, salsa in the refrigerator for residents' personal food was observed without a date and with mold growth on top, and the Dietary Manager stated dietary staff was not responsible for dating residents' food. At the same time, a large amount of water was observed on the top shelf of that refrigerator. The report cited 2022 FDA Food Code sections 3-305.11 and 3-501.17 regarding protected food storage and date marking of refrigerated ready-to-eat TCS food.
Infection Prevention and Water Management Deficiency
Penalty
Summary
Provide and implement an infection prevention and control program was deficient because the facility did not have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). During interview, the Maintenance Supervisor stated that room [ROOM NUMBER] had a non-operational shower water line that was not being flushed and had been non-operational for over a year. At the time of observation, the shower did not have a faucet handle and did not appear to be able to be turned on at the shower wall. Record review of the facility's water management document, Control Measures and Actions, showed that under the Facility Control Measures section, maintenance runs faucets and flushes toilets throughout the facility during monthly rounds.
Medication Administration Errors During Morning Pass
Penalty
Summary
The facility failed to ensure medications were administered in accordance with physician orders without errors for 1 of 3 residents observed during medication administration, resulting in a medication error rate of 8.33% (3 errors out of 36 opportunities). During an observation on 12/04/2025 at 7:38 AM, RN D administered 10 of the 22 medications scheduled for Resident #17’s morning pass and gave 1 tablet of vitamin C, 1 capsule of vitamin D3, and 1 capsule of potassium chloride. When asked about the potassium chloride order, RN D stated it was for only 1 capsule. A subsequent medication reconciliation using the resident’s Order Summary showed the resident was ordered ascorbic acid 250 mg, 4 tablets; potassium chloride extended release 10 mEq, 2 tablets; and vitamin D3 25 mcg (1,000 unit), 2 capsules. The DON was notified of the medication errors during an interview later that day.
Failure to Implement Hot Liquid Policy Results in Resident Burn
Penalty
Summary
A deficiency occurred when the facility failed to implement its hot liquid policy for a resident with advanced cognitive impairment and multiple physical limitations, resulting in a second-degree burn from a hot chocolate spill. The resident, who had diagnoses including Alzheimer's disease, muscle weakness, cognitive communication deficit, reduced mobility, and Parkinson's disease, required supervision or touching assistance for eating. On the day of the incident, the resident refused to go to the dining room and was served hot chocolate in bed without a lid, despite being identified as high risk for hot food and liquid injuries. The hot chocolate was served from a new machine that produced hotter beverages, and staff did not document the temperature of the hot beverage at dinner, as required by policy. Staff interviews revealed that the resident was provided with double protection (a towel and a clothing protector) but still managed to spill the hot chocolate, resulting in burns to the chest and abdomen. The incident was immediately responded to by staff, who removed the resident's clothing and applied cool towels. Subsequent assessments documented blistering, skin loss, and the need for wound care. The resident's care plan indicated that hot liquids should only be consumed while sitting at a table, but this intervention was not followed during the incident. Further review showed that the facility had not completed the required Hot Food/Liquid Assessment for the resident since more than two years prior, despite policy requiring quarterly assessments. The dietary department also failed to monitor and document hot beverage temperatures on the tray line for the meal in question. Staff and family interviews highlighted concerns about the temperature of beverages from the new machine and the lack of lids for hot drinks, which were not addressed prior to the incident.
Failure to Implement Care Plans for Skin Breakdown Prevention
Penalty
Summary
The facility failed to implement care planned interventions for the prevention of skin breakdown in two residents. Resident #20, a severely cognitively impaired female with a history of stroke and hand contractures, was observed multiple times without her prescribed bilateral hand splints, which were intended to prevent skin breakdown. Despite care plan instructions to wear the splints during the day, observations over several days showed that the splints were not in place, and the resident's television, which was supposed to be on for stimulation, was also off. Interviews revealed that the resident disliked the splints, but this refusal was not documented in her care plan. Resident #16, also severely cognitively impaired, was noted to have a reddened area on her coccyx, indicating a risk for skin breakdown. Her care plan included frequent repositioning and the use of soft foam boots to relieve pressure on her feet. However, observations showed that the resident did not have the foam boots on while in her Broda chair or in bed, contrary to the care plan instructions. There was no documentation of the resident refusing to wear the boots or any behaviors that would explain their absence. The Director of Nursing acknowledged that care planned interventions should be implemented and followed by the facility staff. The lack of adherence to the care plans for both residents indicates a failure in executing prescribed interventions, which are crucial for preventing skin breakdown and ensuring the residents' well-being.
Deficiencies in Resident Assessment and Medication Administration
Penalty
Summary
The facility failed to adhere to professional standards of nursing practice in the comprehensive assessment and medication administration for two residents. For one resident, a male with diagnoses including lymphedema, urine retention, heart failure, and kidney disease, the facility did not conduct a comprehensive physical and neurological examination after the resident exhibited confusion and anxiety. Despite the resident's altered mental status, there was no documentation of a pain assessment, abdominal palpation, or notification to the provider about the change in neurological status. The resident's condition worsened over four hours, leading to a hospital transfer where he was diagnosed with severe sepsis and acute renal failure. The facility's records for this resident showed a lack of documented vital signs assessments from mid-July to late September, which was confirmed by the Director of Nursing. The facility's policy required that vital signs be assessed monthly or more frequently if there was a change in condition, but this was not followed. The hospital records indicated that upon arrival, the resident was hypotensive and tachycardic, requiring significant medical intervention. For another resident, a female with chronic pain, the facility failed to properly document the administration of a controlled substance, pregabalin. The medication was not signed out as administered on a specific morning, and discrepancies were found during a narcotic count. Additionally, there were instances where medication was removed without a witness signature, contrary to the facility's policy on controlled substances. The Director of Nursing acknowledged that licensed nurses were expected to follow these policies and professional standards when handling controlled medications.
Medication Cart Left Unlocked and Unattended
Penalty
Summary
The facility failed to secure one of its medication carts, specifically the North Hall Medication Cart, which was left unlocked and unattended in the hallway outside a resident's room. This incident was observed by a surveyor on the afternoon of October 14, 2024. Registered Nurse (RN) B was seen partially closing the top drawer of the medication cart and walking away, leaving it unlocked. The surveyor was able to open the top drawer without any staff noticing, and the cart remained unattended for approximately five minutes, during which time staff, residents, and visitors passed by without securing it. When RN B returned to the cart, she did not use her keys to unlock it, indicating she was aware it was already unlocked. Despite being questioned by the surveyor, RN B denied leaving the cart unlocked. Interviews with other staff, including a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), confirmed that the expectation was for medication carts to be locked when unattended. The facility's policies also required that all medications and biologicals be securely stored in locked compartments, which was not adhered to in this instance.
Failure to Implement Transmission-Based Precautions for Suspected C. diff Case
Penalty
Summary
The facility failed to implement transmission-based precautions and utilize appropriate personal protective equipment for a resident suspected of having a Clostridium difficile infection (C. diff). The resident, an elderly male with a history of lymphedema, urine retention, heart failure, and kidney disease, was admitted to the facility and later tested for C. diff due to symptoms of diarrhea. Despite the suspicion of C. diff, the resident was not placed in contact precautions pending the laboratory results, which were initially negative but suggested possible colonization. The delay in implementing isolation measures was confirmed by the absence of signage on the resident's door and the lack of personal protective equipment used by staff and visitors entering the room. The Director of Nursing (DON) acknowledged that the resident should have been placed in isolation as a precaution while awaiting test results. However, a miscommunication led to the contact isolation sign being placed on the wrong resident's door. During observations, it was noted that a therapy staff member and a Certified Nursing Assistant (CNA) entered the resident's room without wearing PPE, despite the resident reporting ongoing diarrhea. The DON later confirmed that the resident would remain in contact precautions following the laboratory interpretation, which did not provide a definitive result, and planned to consult with the local health department for further guidance.
Failure to Provide Adequate Supervision to Prevent Falls
Penalty
Summary
The facility failed to provide adequate supervision to prevent falls for three residents, resulting in one resident sustaining a hip fracture and the potential for serious injuries to the other two residents. Resident 1, who had severe cognitive deficits and a history of unsafe behaviors, was found on the floor with a hip fracture after an unwitnessed fall. The resident was known to self-transfer and wander, and there was no structured supervision or documentation of her unsafe behaviors. The night shift staff reported being understaffed and unable to adequately supervise residents with dementia who were awake at night. Resident 2, who had a history of falls and required assistance with personal care, was observed moving independently in her wheelchair without staff supervision. The resident was known to self-transfer and fall, but there were no interventions in place to supervise her when she was awake. The facility's care plan for Resident 2 did not include any specific measures for supervision, and the resident had experienced multiple unobserved falls. Resident 3, who had dementia and required assistance with walking and transfers, also had a history of unobserved falls. The resident's care plan did not include any interventions for supervision when she was awake. The resident's husband reported that he visited daily to assist with her care, but there were no structured programs or activities provided by the facility to supervise her. The facility's staff confirmed that there were no designated staff to watch residents with unsafe behaviors and that they were in the process of developing a program to address this issue.
Lack of Meaningful Activities Program for Residents
Penalty
Summary
The facility failed to develop and implement a meaningful activities program for four residents, resulting in them sitting unsupervised and experiencing boredom without the option for diversional activities to decrease the risk of injury. Resident R4, a [AGE] year-old female with dementia and a history of falls, was observed sitting in a wheelchair near the nurse's station without any activities or supervision. Her care plan did not include necessary interventions for supervision or diversional activities, and staff confirmed that no new interventions were put in place for her safety after a recent fall. The facility did not have an activity director or aide on staff, and there was no documentation of an activities program for residents with cognitive impairments and poor safety awareness. Resident R1, a [AGE] year-old female with severe cognitive impairment, was also observed sitting in front of the nurse's station without any activities or consistent staff presence. Her care plan included approaches for diversional activities, but there was no documentation indicating that these activities were offered. The facility's social worker confirmed that R1's competency was under review, but no risk-benefit statement or assurance of her understanding of the risks related to lack of supervision was provided. The facility did not have an activity calendar for April 2024, and staff were unable to provide information on how they were supervising R1 when she was awake. Residents R2 and R3, both with significant medical diagnoses and cognitive impairments, were similarly observed sitting at the nurse's station without activities or consistent supervision. Their care plans included approaches for diversional activities and supervision, but there was no documentation showing that these activities were offered. The facility's treatment team acknowledged the lack of an activity program and confirmed that they were making attempts to provide some activities using CNAs and licensed nurses. However, they did not have a calendar or scheduled activities for the month of April and were unable to provide documentation of activities offered to the residents.
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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 North Muskegon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Harbor Terrace Senior Living | 2.6 mi | ★★★★★ | 10 | 0 |
| Lake Woods Nursing & Rehabilitation Center | 3.8 mi | ★★★★★ | 2 | 0 |
| Optalis Health & Rehabilitation Of Muskegon | 4.1 mi | ★★★★★ | 40 | 0 |
| Roosevelt Park Nursing And Rehabilitation Communit | 4.9 mi | ★★★★★ | 3 | 0 |
| Christian Care Nursing Center | 5 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.