Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Hill Crest Manor during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of wandering exited the facility through a door with a malfunctioning alarm system, which reset after the door closed instead of alerting staff continuously. Staff were unaware of the resident's absence until notified by another resident, and the individual was found and returned by a former employee after traveling a significant distance. The incident was attributed to the disengaged door/alarm system and lack of immediate staff supervision.
The facility failed to respect residents' rights to privacy and dignity, with staff entering rooms without knocking and discussing residents' conditions openly. A visually impaired resident did not receive necessary verbal cues during meals, and another resident's grooming needs were neglected due to the absence of a beautician.
The facility failed to honor resident choice for showers and dietary preferences. A resident with a history of stroke and another with diabetes and depression received fewer showers than preferred, while a third resident with multiple diagnoses was not provided with preferred food items like fresh fruit and yogurt. Staff interviews confirmed inconsistencies in providing showers and dietary options.
The facility did not address or resolve grievances raised by residents during council meetings, such as dietary issues, staff behavior, and missing laundry. Despite policy requirements for investigation and corrective action, no follow-up or communication was provided to residents, leading to a deficiency in honoring their rights.
The facility did not maintain a surety bond equal to or greater than 1.5 times the average monthly balance for the residents' trust fund (RTF) account over the past year. The bond amount was reduced from $65,000 to $58,000, which was insufficient given the average monthly balance of $39,259.28, requiring a bond of at least $58,500. This affected all residents with funds in the RTF account.
The facility did not annually inform residents of their rights, affecting all 11 residents in a group interview. The policy requires informing residents of their rights, but resident council minutes showed the rights section was left blank for three consecutive months. During a group meeting, residents confirmed their rights were not discussed. The Activity Director was unaware of the required frequency for providing notice of rights, and the Administrator acknowledged the oversight.
The facility did not effectively communicate information about the State Long-Term Care Ombudsman program to residents. During a group meeting, all residents were unaware of the Ombudsman's role or contact information. The Activity Director admitted to not recently discussing this information, and the Administrator confirmed that staff should inform residents about the Ombudsman, highlighting a communication lapse.
The facility did not distribute mail to residents on Saturdays, despite mail being delivered to the facility. During a resident group meeting, all attendees confirmed the lack of Saturday mail distribution. The facility's policy ensures residents' access to mail, but this was not followed. Interviews revealed that the responsibility for distributing mail on Saturdays fell to on-call managers, but this was not being done.
The facility failed to inform residents about the grievance process, as 11 residents expressed uncertainty about filing grievances. The facility's policy outlines the grievance process, but it was not communicated to residents, as shown by the lack of documentation in meeting minutes. Staff interviews revealed that the grievance process was not discussed with residents, leading to confusion and a violation of their rights.
The facility did not conduct timely Employee Disqualification List (EDL) checks for five employees and failed to verify the CNA Registry for a Registered Nurse, contrary to its Abuse and Neglect policy. Interviews revealed that EDL checks were not routinely performed, and the Administrator expected these checks to be completed per policy.
The facility failed to conduct care plan meetings quarterly or upon significant changes in residents' conditions, affecting five residents. Residents and their representatives were not involved in the care planning process, contrary to the facility's policy. Interviews revealed a lack of documentation and coordination in scheduling and conducting these meetings.
Facility staff failed to follow safety protocols during resident transfers and wheelchair use, leading to potential accident hazards. A resident was transferred using a mechanical lift without spreading the lift's legs for stability, and two residents were pushed in wheelchairs without foot pedals, contrary to facility policy.
The facility did not ensure that nurse aides met the required qualifications, as three aides lacked documentation of certification within four months of hire. The Administrator confirmed the requirement for certification but the facility lacked a policy on hiring and training nurse aides.
The facility failed to manage and store medications properly, with expired medications found in the medication cart and room, and loose pills in the carts. An opened vial of tuberculin lacked a date, and insulin pens were unlabeled. Staff left medications at a resident's bedside, contrary to policy. A CMT and the DON confirmed these practices were incorrect.
The facility exhibited deficiencies in food safety and hygiene practices, including improper labeling and storage of food, inadequate hand hygiene, and failure to monitor food and refrigerator temperatures. Staff did not label or seal opened food items, and dishes were improperly stored. Hand hygiene was neglected, with staff failing to wash hands between tasks. Additionally, food temperatures were not checked before serving, and refrigerator temperature logs were incomplete.
The facility failed to maintain safe operating conditions for wheelchairs, affecting three residents. One resident, who was moderately cognitively impaired, had a wheelchair arm taped on the left side. Another resident, cognitively intact and using a wheelchair for mobility, had armrests taped with white tape. A third resident, also cognitively intact and dependent on a wheelchair, had a left armrest wrapped in white tape. Interviews with staff revealed awareness of the issue, but wheelchairs were not maintained as expected.
The facility failed to transmit MDS assessments within the federally mandated timeframe for a resident. The resident was admitted and discharged without the discharge assessment being transmitted. The MDS/Care Plan Coordinator could not explain the delay, and the facility lacked a policy on MDS transmittals. The Administrator noted that MDS should be submitted timely and reviewed by an RN.
A facility failed to obtain routine PT/INR orders for a resident on Coumadin, continuing medication administration without monitoring its effects. The resident's care plan indicated a risk of bleeding and required regular lab tests, which were not scheduled or conducted. The resident expressed concern over the lack of monitoring, leading to refusal of medication. The DON confirmed the absence of necessary physician orders for PT/INR tests, highlighting a lapse in medication management procedures.
A resident with severe cognitive impairment and impaired vision did not have their missing prescription eyeglasses replaced for several weeks. The Social Services Director failed to ensure timely replacement and communication with the resident's representative, leading to a deficiency in quality care.
The facility failed to provide adequate personal hygiene care for residents, resulting in deficiencies in shaving, showering, and nail care. A resident with cognitive impairment did not receive regular shaving and was given only two showers in a month. Another resident had overgrown nails with a substance underneath, and the facility did not provide regular nail care. A third resident, requiring substantial assistance with bathing, reported receiving only two showers in a month. Staff interviews revealed challenges in adhering to the shower schedule due to low staffing levels.
A resident with moderate cognitive loss and mental health issues eloped from an LTC facility due to inadequate supervision and failure to identify elopement risk. Despite exhibiting exit-seeking behavior, the resident was not reassessed as an elopement risk, leading to their unsupervised departure. Staff interviews revealed communication gaps and lack of awareness regarding the resident's risk and necessary safety measures.
A resident with no cognitive loss and multiple health conditions felt disrespected when a CNA made a derogatory religious comment on Easter Sunday. The CNA admitted to the statement, while the DON was unaware and stated it was inappropriate, violating the facility's policies on resident rights and dignity.
Resident Elopement Due to Faulty Door Alarm and Inadequate Supervision
Penalty
Summary
A resident with diagnoses of dementia, depression, Alzheimer's disease, and stage 3 chronic kidney disease eloped from the facility through an unsecured and improperly alarmed exit door. The resident was able to exit the south exit door without staff observation, and the door alarm, which was intended to sound continuously until reset by staff, ceased once the door closed. This malfunction allowed the resident to leave the premises undetected by staff. The resident was not immediately noticed missing by staff; instead, another resident witnessed the elopement and alerted a CNA, who then informed an LPN to initiate a search. The resident was found and returned to the facility by a former employee approximately 20 minutes later, after having traveled about one third of a mile on foot. Upon return, a full physical and psychosocial assessment was conducted, and no concerns were noted. The facility's investigation determined that the root cause of the incident was the disengagement of the door/alarm system, which allowed the alarm to reset improperly. Staff interviews confirmed that the alarm system was old and not functioning as intended, and that staff were unaware of the resident's exit until notified by another resident. The resident was identified as an elopement risk with impaired safety awareness, and the care plan included monitoring and diversional interventions, but these were not sufficient to prevent the incident.
Violation of Resident Privacy and Dignity
Penalty
Summary
The facility failed to honor residents' rights to privacy and dignity, as evidenced by multiple instances where staff entered residents' rooms without knocking or announcing themselves. This was observed with several residents, including one who expressed that staff never knocked and entered as if they owned the place. Additionally, staff were observed discussing residents' conditions openly in hallways, compromising their privacy and dignity. In one instance, a resident with visual impairments was not provided with necessary verbal cues during meals, leaving them with food on their hands without assistance. Staff failed to announce themselves or explain their actions to the resident, which was crucial given the resident's visual limitations. This lack of communication and respect for the resident's needs was a clear violation of their right to a dignified existence. Another resident's personal grooming needs were neglected, as their hair was left unmanaged and uncut for months due to the absence of a beautician. Despite the resident's family expressing concerns, the facility did not ensure regular haircuts or grooming, further compromising the resident's dignity. These deficiencies highlight a pattern of neglect in maintaining residents' rights to privacy, dignity, and personal care.
Failure to Honor Resident Choice in Showers and Dietary Preferences
Penalty
Summary
The facility failed to honor the right to self-determination and resident choice for three residents. Resident #12, who had a history of stroke and muscle weakness, was not provided with the preferred number of showers per week, receiving only one shower weekly over several weeks. The resident expressed dissatisfaction with the lack of choice regarding shower frequency, stating a preference for at least two showers per week. Similarly, Resident #25, diagnosed with diabetes, obesity, and depression, also received only one shower per week, despite expressing a desire for more frequent showers. Interviews with staff confirmed that showers were not consistently provided twice a week as preferred by the residents. Resident #42, with intact cognitive skills and multiple diagnoses including heart disease and diabetes, was not provided with preferred food items such as fresh fruit, yogurt, and cheese, despite these preferences being communicated to the dietician upon admission. The resident expressed frustration over the lack of healthy food options and the need to rely on family for preferred foods. The dietician confirmed that resident preferences were entered into the system, but the dietary manager indicated that residents needed to request specific foods from kitchen staff. The administrator acknowledged that the facility should have had the preferred food items available but admitted that fresh fruit was not always on hand.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to address and resolve grievances raised by residents during resident council meetings, as evidenced by the lack of documented actions or responsible parties in the council minutes. Issues such as dietary concerns, rude and rough behavior by staff, delayed response to call lights, and missing laundry items were repeatedly brought up by residents without any follow-up or communication on resolutions. The facility's policy on grievances requires investigation and corrective action, but this process was not followed, leaving residents' concerns unaddressed. During interviews, residents expressed that their concerns were not communicated back to them after being raised in meetings. The Activity Director confirmed that concerns were distributed to department heads and administration but did not receive feedback to report back to residents. The Administrator and DON were unaware of specific issues reported by the resident council, indicating a breakdown in communication and follow-up. This lack of action and communication led to a deficiency in honoring residents' rights to have their grievances addressed and resolved.
Facility Fails to Maintain Adequate Surety Bond for Resident Trust Funds
Penalty
Summary
The facility failed to maintain a surety bond that was equal to or greater than one and one-half times the average monthly balance for the residents' trust fund (RTF) account over the last 12 consecutive months, from January 2024 to December 2024. The facility's policy required that the bond amount should cover at least one and one-half times the annual average of the fund account, including any credit balances. However, the facility's current approved bond amount was $58,000, which was insufficient as the average monthly balance for the RTF account was $39,259.28, necessitating a bond of at least $58,500. The deficiency was identified during a record review and interviews with facility staff. The Business Office Manager acknowledged that the surety bond should be sufficient to cover 1.5 times the average amount held in accounts. Despite having a larger surety bond previously, the facility decreased the bond amount from $65,000 to $58,000 in December 2024. The Administrator also confirmed the expectation that the surety bond should equal 1.5 times the average monthly account total held in the resident trust accounts. This oversight had the potential to affect all residents with funds held in the RTF account, given the facility's census of 58.
Failure to Annually Inform Residents of Their Rights
Penalty
Summary
The facility failed to annually inform residents of their rights, affecting all 11 residents who participated in a group interview. The facility's policy, revised in February, mandates that employees treat residents with kindness, respect, and dignity, and that residents be informed of their rights and responsibilities as guaranteed by federal and state laws. However, a review of resident council minutes from November, December, and January showed that the section for resident rights was left blank. During a group meeting, all 11 residents confirmed that their rights were not discussed in their monthly resident council meetings. The Activity Director, who assisted in setting up these meetings, was unaware of the frequency with which the facility must provide a notice of rights and services. The Administrator acknowledged that resident rights should be discussed at these meetings.
Failure to Inform Residents About Ombudsman Program
Penalty
Summary
The facility failed to provide accessible information about the State Long-Term Care Ombudsman program to its residents. During a resident group meeting, all 11 residents present were unaware of what the Ombudsman was, their role, or where to find information about the program within the facility. An observation revealed that the Ombudsman information was located in the hall by the living room area, but it was not effectively communicated to the residents. The Activity Director acknowledged that while they had previously discussed the Ombudsman information, it had not been recently addressed with the residents. The Administrator confirmed that staff should inform residents about the Ombudsman, their role, and contact information, indicating a lapse in communication and education regarding resident rights and external advocacy resources.
Failure to Deliver Saturday Mail to Residents
Penalty
Summary
The facility failed to deliver Saturday mail to its residents, as revealed during a resident group meeting where all 11 attendees reported that mail was not distributed on Saturdays. The facility's policy on resident rights, revised in February 2024, guarantees residents access to mail, yet this was not adhered to. Interviews with the Activity Director and the Administrator confirmed that while mail is delivered to the facility on Saturdays, it is not distributed to residents until Monday. The Activity Director noted that a resident previously retrieved mail from the mailbox and placed it in the office, but this practice had ceased. The Administrator acknowledged that on-call managers are responsible for distributing mail on Saturdays, but this was not occurring.
Residents Uninformed About Grievance Process
Penalty
Summary
The facility failed to ensure that residents were informed about the grievance process, which is a violation of their rights. During a group meeting, 11 out of 11 residents expressed uncertainty about how to file a grievance, whether anonymously or in writing, and how to obtain a written decision regarding their grievances. The facility's policy on grievances, revised in April 2017, outlines the process for investigating and resolving grievances, including the roles of the grievance officer and the maintenance of a grievance log. However, the policy was not effectively communicated to the residents, as evidenced by the lack of documentation in the resident council meeting minutes from November 2024 to January 2025, which did not indicate whether residents were informed about the grievance process. Interviews with facility staff further highlighted the deficiency. The Activity Director admitted to not having discussed the grievance process with the residents, including where to find the necessary paperwork or whom to contact. Additionally, the Administrator mentioned that grievances would be addressed by the interdisciplinary team, but there was no indication that this information was communicated to the residents. This lack of communication and education regarding the grievance process led to the residents' confusion and uncertainty, thereby failing to uphold their rights to voice grievances without discrimination or reprisal.
Failure to Conduct Timely Background Checks
Penalty
Summary
The facility failed to adhere to its own Abuse and Neglect policy by not conducting Employee Disqualification List (EDL) checks prior to the hire dates for five out of eight employees. These employees included a Dietary Aide, two Nurse Aides, a Maintenance Director, and another staff member. Additionally, the facility did not verify the Certified Nurses' Assistant (CNA) Registry for one of the eight sampled staff, a Registered Nurse, to ensure they did not have a Federal Indicator for abuse or neglect. The facility's policy required EDL checks at the time of employment consideration, and any candidate on the list was not eligible for hire. However, the records showed that EDL checks were either not conducted or were completed after the employees had already been hired. Interviews with facility staff revealed inconsistencies in the implementation of the policy. The Business Office Manager admitted to only checking the EDL upon hire and not routinely, and acknowledged the oversight in checking the nurse aide registry for all employees. The Regional Accounting person stated that EDL checks were supposed to be completed quarterly for all employees, which was not being done. The Administrator confirmed that EDL and CNA registry checks were expected to be completed per facility policy and upon hire, indicating a lapse in following established procedures. This failure to implement the policy as intended led to the deficiency noted in the report.
Failure to Conduct Timely Care Plan Meetings and Involve Residents
Penalty
Summary
The facility failed to conduct care plan meetings on a quarterly basis or when a resident experienced a significant change in condition, as required by their Care Planning Policy. This deficiency affected five residents out of the 15 sampled, with a facility census of 58. The policy mandates that the interdisciplinary team, along with the resident and their family or legal representative, develop and implement a comprehensive, person-centered care plan. However, the facility did not adhere to this policy, resulting in residents and their representatives not being involved in the care planning process. Resident #24, who had intact cognitive skills and multiple diagnoses including kidney disease and diabetes, expressed frustration at not being involved in their care planning. Similarly, Resident #32, with severe cognitive impairment and diagnoses such as Alzheimer's disease, experienced a change in mobility from using a walker to a wheelchair without a care plan meeting to address this change. The Durable Power of Attorney for Resident #32 was informed of the change but noted the absence of a care plan meeting. Resident #42, with intact cognitive skills and various diagnoses including heart disease and diabetes, reported only being invited to one care plan meeting since admission. Resident #16 and Resident #21, both with intact or moderately impaired cognitive skills, also reported not being invited to or attending care plan meetings. Interviews with facility staff, including the MDS Coordinator and Social Services Director, revealed a lack of documentation and coordination regarding care plan meetings, contributing to the deficiency in involving residents and their representatives in the care planning process.
Failure to Follow Safety Protocols in Resident Transfers and Wheelchair Use
Penalty
Summary
The facility staff failed to ensure residents remained free from accident hazards by not adhering to the manufacturer's guidelines during resident transfers and wheelchair use. Specifically, Resident #8 was transferred using a mechanical lift without spreading the lift's legs for stability, contrary to the manufacturer's instructions. This oversight was observed during a transfer from a chair to a bed, where the lift's legs remained closed, posing a risk of instability. Interviews with staff revealed inconsistent understanding of the proper use of the mechanical lift, with some staff members incorrectly believing the legs should remain closed during transfers. Additionally, the facility staff did not ensure the safe transport of residents in wheelchairs by failing to use foot pedals. Resident #11 was observed being wheeled without foot pedals, which was only corrected after intervention by the Director of Nursing. Similarly, Resident #30 was pushed in a wheelchair with only one foot pedal, leaving one foot on the floor. Interviews with staff confirmed that pushing residents without foot pedals is against facility policy, as it could lead to injury. The facility's policies on resident handling and wheelchair use were not adequately followed, leading to these deficiencies. The policies require that resident transfer status be documented and reviewed, and that wheelchairs be used according to resident choice and safety needs. However, the observed practices did not align with these policies, indicating a lapse in adherence to established safety protocols.
Failure to Ensure Nurse Aide Certification
Penalty
Summary
The facility failed to ensure that nurse aides met the minimum qualifications required by not providing evidence of satisfactory participation in a State-approved nurse aide training and competency evaluation program within four months of hire. The facility's employee list revealed that three nurse aides, hired on different dates, lacked documentation of certification in their personnel files. Specifically, NA A, NA D, and NA E, who were hired on 6/5/24, 12/19/22, and 5/19/23 respectively, did not have records showing they were certified. During an interview, the Administrator acknowledged that nurse aides should obtain their certification within four months of their hire date, but the facility did not have a policy regarding the hiring and training of nurse aides.
Medication Management and Storage Deficiencies
Penalty
Summary
The facility failed to properly manage and store medications and biologicals, leading to several deficiencies. Observations revealed expired medications and biologicals in the medication cart and room, including an opened vial of tuberculin without a date, insulin pens without pharmacy labels, and various expired medications such as Tussin cough suppressant, liquid iron supplements, and Salonpas pain relieving patches. Additionally, loose pills were found in both the South and North medication carts, indicating a lack of proper medication management and storage practices. Furthermore, staff were observed leaving medications at the bedside of a resident, which is against the facility's policy. The resident reported that staff would leave pills for them to take later, which was confirmed by a Certified Medication Technician (CMT) and the Director of Nursing (DON), both of whom acknowledged that medications should not be left at the bedside and that staff should ensure residents take their medications. These actions and inactions demonstrate a failure to adhere to the facility's medication storage policy and ensure the safe administration of medications to residents.
Deficiencies in Food Safety and Hygiene Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple observations of improper food handling and storage practices. Staff did not label or date opened food items, such as smoked sausage and bread, and failed to seal them properly. Additionally, food storage containers and dishes were not stored in a manner that prevents contamination, with items like measuring cups and butter bowls left uncovered. Interviews with the Dietary Manager, Dietician, and Administrator confirmed that these practices did not meet their expectations for food safety. Hand hygiene practices were also found to be lacking, with staff failing to wash or sanitize their hands between tasks, such as after touching a resident's wheelchair and before continuing to prepare food. Observations showed that staff did not wash their hands upon entering the kitchen or when transitioning between different food preparation tasks. The Administrator and Dietician both expressed that they expected staff to maintain proper hand hygiene to prevent cross-contamination. Furthermore, the facility did not have policies in place for monitoring food temperatures or recording refrigerator temperatures. Observations revealed that staff did not check the temperature of food items on the steam table before serving them to residents. Additionally, there were missing entries in the refrigerator temperature logs, indicating a lack of consistent monitoring. Interviews with the Dietary Manager, Dietician, and Administrator highlighted the expectation that these temperatures should be regularly checked and recorded to ensure food safety.
Facility Fails to Maintain Safe Wheelchair Conditions
Penalty
Summary
The facility failed to maintain resident wheelchairs in safe operating condition, as observed in the cases of three residents. Resident #11, who was moderately cognitively impaired and dependent on a wheelchair, was found with a wheelchair arm taped on the left side. Resident #57, who was cognitively intact and used a wheelchair for mobility outside their room, had wheelchair armrests taped with white tape. Resident #60, also cognitively intact and dependent on a wheelchair due to a lower extremity impairment, had a left wheelchair armrest wrapped in white tape. These observations indicate that the wheelchairs were not maintained in a safe and operable manner, as required by the facility's maintenance policy. Interviews with facility staff, including the Maintenance personnel, Director of Nursing, and Administrator, revealed an awareness of the issue, with the Maintenance staff acknowledging that several wheelchairs needed repairs. The Director of Nursing and Administrator both expressed expectations that residents' wheelchairs should be in good repair and free of torn armrests. Despite these expectations, the facility did not ensure that the wheelchairs were maintained in a condition that met the residents' rights to a safe and comfortable environment.
Failure to Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to ensure the timely transmission of Minimum Data Set (MDS) assessments for one of the sampled residents, specifically Resident #49. The resident was admitted on July 27, 2024, and discharged on August 15, 2024. However, the discharge assessment was completed on August 15, 2024, with no transmission accepted date listed for the assessment. During interviews, the MDS/Care Plan Coordinator, who had been in the position for two years, was unable to explain why the MDS was marked as 'export ready' and could not print a transmission report. The Administrator acknowledged that MDS should be submitted timely and mentioned that a Registered Nurse (RN) would need to review it. The facility did not provide a policy regarding MDS assessment transmittals.
Failure to Monitor Anticoagulant Therapy
Penalty
Summary
The facility failed to ensure routine orders for prothrombin time (PT) and international normalized ratio (INR) were obtained for a resident on anticoagulant medication, specifically Coumadin (Warfarin). Despite the absence of orders to monitor the medication's effect, staff continued to administer the anticoagulant. This oversight affected one resident, who was part of a sample of 15 residents, in a facility with a census of 58. The resident's PT/INR flow sheet showed several instances where the next PT/INR test date was left blank, indicating a lack of scheduled monitoring. The resident's care plan, revised in January 2025, highlighted the risk of bleeding due to anticoagulant therapy and the need for regular lab tests to monitor PT/INR levels. However, the resident reported not having a PT/INR test drawn in a long time, leading to their refusal to take Coumadin due to concerns about the lack of monitoring. Interviews with the Director of Nursing (DON) confirmed that there should have been a physician's order for regular PT/INR lab tests for residents on Coumadin. The DON acknowledged that if there was an order to recheck PT/INR in two weeks, it should have been completed. This deficiency in monitoring and documentation of PT/INR levels for a resident on anticoagulant therapy represents a significant lapse in the facility's adherence to its own policies and procedures for safe medication management.
Failure to Replace Missing Prescription Eyeglasses
Penalty
Summary
The facility failed to provide quality care by not assisting a resident in replacing their prescription eyeglasses, which had been reported missing for several weeks. The resident, who had severe cognitive impairment and required corrective lenses, was observed without eyeglasses. The resident's representative reported the loss to the Social Services Director, who initially found reading glasses that did not belong to the resident. Despite being informed of the issue, the Social Services Director did not ensure the replacement of the prescription eyeglasses in a timely manner. Interviews revealed a lack of communication and follow-through regarding the scheduling of an appointment for the replacement of the eyeglasses. The Social Services Director was unsure of who was responsible for notifying the resident's representative about the appointment, and there was no documentation of such communication in the resident's medical record. The facility's Administrator confirmed that the Social Services Director should have notified the resident's representative and documented the communication, highlighting a breakdown in the process of addressing the resident's needs.
Deficiencies in Personal Hygiene Care for Residents
Penalty
Summary
The facility failed to provide necessary services for activities of daily living (ADLs) to dependent residents, resulting in deficiencies in personal hygiene care. Resident #1, who had moderate cognitive impairment and severe vision impairment, did not receive regular shaving and was only given two showers in a month, despite being scheduled for twice-weekly showers. The resident expressed dissatisfaction with the infrequent showers and the presence of chin hairs, which were bothersome. The facility's records showed inconsistencies in documenting the showers and shaving services provided to the resident. Resident #2, who was cognitively intact but required assistance with personal hygiene, had overgrown nails with a brown/black substance underneath. The resident expressed a preference for having their nails cut, but the facility failed to provide regular nail care. The Director of Nursing acknowledged the need for nail care but had not ensured it was performed. The facility's documentation did not reflect consistent nail care, and the resident received only four of the nine scheduled showers in the past month. Resident #3, also cognitively intact, required substantial assistance with bathing but reported receiving only two showers in the past month. The resident felt unclean due to the infrequent showers and noted that staff sometimes offered showers at inconvenient times, such as late at night. The facility's records showed discrepancies in the number of showers documented, and the resident's care plan lacked specific preferences for bathing. Interviews with staff revealed challenges in adhering to the shower schedule, particularly when staffing levels were low, impacting the delivery of care.
Resident Elopement Due to Inadequate Supervision and Risk Assessment
Penalty
Summary
The facility failed to provide adequate supervision and identify an elopement risk, resulting in a resident eloping from the facility. The resident, who had a history of moderate cognitive loss and various mental health diagnoses, was initially assessed as not being an elopement risk. However, subsequent notes indicated the resident exhibited exit-seeking behavior and wandering, yet these behaviors were not adequately addressed in a timely manner. On multiple occasions, the resident demonstrated behaviors consistent with an elopement risk, such as exit-seeking and verbalizing intentions to leave the facility. Despite these indicators, the resident was not immediately reassessed as an elopement risk, and the necessary safety measures were not implemented. The resident eventually left the facility unsupervised and was missing for approximately one hour before being returned by a neighbor. Interviews with staff revealed a lack of communication and awareness regarding the resident's elopement risk and the implementation of 15-minute checks. The Director of Nursing and other staff members were not fully informed or did not act upon the resident's behaviors and the need for increased supervision, leading to the resident's unsupervised departure from the facility.
Resident Rights Violation Due to Derogatory Religious Comment
Penalty
Summary
The facility failed to uphold resident rights and dignity when a staff member made a derogatory religious statement to a resident. The incident involved a resident with no cognitive loss, as indicated by a Brief Interview of Mental Status (BIMS) score of 15, who was dependent on a wheelchair and required varying levels of assistance for daily activities. The resident, who had diagnoses including heart attack, obesity, and anxiety disorder, reported feeling hurt and disrespected when a staff member greeted them with 'happy zombie Jesus day' on Easter Sunday. The staff member, a Certified Nurse Aide (CNA), admitted to making the statement, believing it was not offensive. However, the Director of Nursing was unaware of the incident and stated that such comments were inappropriate and not in line with the facility's expectations for respectful communication. The facility's policies on resident rights and dignity emphasize treating residents with respect and ensuring they can exercise their rights without interference or discrimination.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 41 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Hamilton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Daviess County Nursing And Rehabilitation | 12.3 mi | ★★★★★ | 0 | 0 |
| Cameron Nursing Center | 13.3 mi | ★★★★★ | 2 | 0 |
| Quail Run Health Care Center | 13.9 mi | ★★★★★ | 1 | 0 |
| Golden Age Nursing Home | 14.5 mi | ★★★★★ | 12 | 0 |
| Sunset Home | 21.6 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Hill Crest Manor.
100% money-back within 48 hours.
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.