Above average — CMS composite of the measures below.
The next survey window likely opens around December 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 Care Center Inc during CMS and state inspections, most recent first.
Open Dumpster Lids and Improper Trash Containment: The facility failed to keep the outside dumpster lids closed and to contain garbage inside the dumpster. Surveyors repeatedly observed open lids with visible trash, boxes, and debris inside. An HSKP staff member discarded trash and left the lid open, and interviews with HSKP, the DM, the MS, and the Administrator confirmed that lids should be closed after trash is discarded.
Staff failed to preserve resident dignity during meals and wound care. A CNA stood over and fed three residents at eye level instead of sitting, and during wound care for a resident, staff left the window curtains and privacy curtain open, removed the brief, and left the resident's peri area exposed while obtaining supplies and continuing care.
The facility failed to provide SNF ABNs to two residents who remained in the facility after skilled Medicare services ended. There was no documentation that the residents or their representatives received the required written notice at least two calendar days before skilled coverage ended, and the SSD stated he/she was unaware the form was needed for residents who chose to stay. The Administrator stated that residents discharged from skilled Medicare services and remaining in the facility should receive a SNF ABN.
Unsafe and Poorly Maintained Common Areas: Surveyors observed dirt and debris on ceiling fans and skylight edges, missing fan blades, peeled paint, exposed sheetrock, damaged molding held with medical tape, holes in walls, and peeled wallpaper in the dining room, nurse's station area, and hallways. The Maintenance Repair Log had no documentation of concerns addressed, and staff interviews showed repairs were expected to be entered in the logbook or reported directly to nursing or maintenance when urgent.
Missing transfer, discharge, and bed-hold notifications: The facility failed to document, obtain signatures for, and send written transfer/discharge and bed-hold information to residents and/or their representatives, including appeal rights and Ombudsman contact information. Four residents who were transferred to the hospital had forms with no bed-hold choice, no daily room rate, no signature, and no proof that the information was provided in writing.
Staff failed to follow infection control practices during wound care for multiple residents, including not consistently using gowns for EBP, not performing hand hygiene after removing gloves, and leaving rooms to get supplies before returning to continue treatment. An LPN stated gowns were only used for infected rooms, while leadership stated hand hygiene should occur before entering and after exiting rooms and gowns should be removed before exiting for residents on EBP. Staff also failed to monitor an ice chest cart, allowing a resident and a visitor to handle the ice scoop and reach into the ice with bare hands while nearby staff did not intervene.
A bookkeeper misappropriated over $20,000 from resident trust accounts and cash by failing to follow required documentation procedures, including obtaining witness signatures and providing detailed reasons for withdrawals. Many affected residents had cognitive impairments and reported not receiving or requesting cash, despite their signatures appearing on disbursement logs. The bookkeeper also failed to deposit funds provided by resident representatives, resulting in missing or unaccounted-for resident funds.
The facility failed to maintain a safe and clean environment, with observations of unsanitary conditions in the smoking area, courtyard, and various indoor locations. Issues included dead insects, cigarette butts, exposed sheetrock, and grime buildup. Staff interviews revealed unclear responsibilities and inconsistent use of maintenance logs, contributing to the neglect of these areas.
The facility failed to provide written notification to residents and their representatives regarding hospital transfers. Four residents were transferred multiple times without documented notifications. Interviews revealed that the required transfer/discharge forms were not completed or maintained, and the Social Service Designee did not follow up on these forms, indicating a systemic issue in the facility's process.
The facility failed to notify residents and/or their representatives in writing of the bed hold policy during hospital transfers. This deficiency was identified for four residents who were transferred multiple times without documented notification. Interviews with staff revealed that the bed hold policy forms were not being completed or maintained, with the ADON, Administrator, and SSD acknowledging lapses in the process.
The facility failed to document and manage pressure ulcers for two residents, leading to deficiencies in care. One resident, with severe cognitive impairment and limited mobility, had an open area on the left buttock without proper documentation or treatment orders. Another resident, also with severe cognitive impairment, had a nickel-sized eschar on the right heel, but heel protectors were not used consistently. Staff interviews revealed a lack of awareness and adherence to care plans, contributing to inadequate care.
The facility failed to document communication between the facility and the dialysis center for residents requiring dialysis. Despite policies requiring a Dialysis Communication Record for each visit, the facility missed numerous opportunities to complete these forms for residents with end-stage renal disease and chronic kidney disease. Interviews revealed inconsistencies in sending communication logs and checking for bruit and thrill, indicating systemic issues in maintaining proper documentation.
The facility failed to provide the required twelve hours of in-service education and annual Dementia Care competencies for two CNAs. CNA C and CNA D did not meet the training requirements, as confirmed by the DON and Administrator.
A resident with multiple health conditions was left unsupervised outside for several hours after falling over a crack in the sidewalk. Despite staff noticing the resident's absence during the night, no search was initiated until the following morning. The resident was found with abrasions and required hospital evaluation.
Open Dumpster Lids and Improper Trash Containment
Penalty
Summary
The facility failed to ensure the outside trash dumpster was maintained to keep pests out and to keep garbage contained inside the dumpster. On multiple observations, the dumpster lids were left open and visible garbage bags, boxes, and other miscellaneous debris were seen inside. During one observation, Housekeeper A discarded a bag of trash into the dumpster and did not close the lid afterward. In interviews, Housekeeper A stated he/she never closed the dumpster lids after throwing away trash and had not been told to do so, while Housekeeper B, the Dietary Manager, the Maintenance Supervisor, and the Administrator each stated that dumpster lids should be closed after staff discarded trash and debris into the dumpster.
Failure to Preserve Resident Dignity and Privacy During Meals and Wound Care
Penalty
Summary
The facility failed to treat residents with dignity and respect when staff stood over and fed three residents during meals instead of sitting at eye level. During observation in the main dining room, a CNA stood over and fed Resident #36 during the noon meal. In the cafe dining room, a CNA stood over and fed Resident #21 during the evening meal and later stood over and fed Resident #33 during the evening meal. The facility policy titled Resident Rights stated that each resident shall be treated with consideration, respect, and full recognition of dignity and individuality, including privacy in treatment and care of personal needs. The facility also failed to maintain privacy during wound care for Resident #80. During observation, a CNA and RN entered the room to perform wound care, but the window curtains were left open, the privacy curtain was not closed, and the resident's front peri area was uncovered and exposed after the brief was removed. The RN left the room to obtain additional supplies while the resident remained exposed, and the privacy curtain was not pulled before the door was opened. The RN then re-entered the room and continued wound care while the resident remained uncovered. During interviews, the RN stated the window curtain and privacy curtain should have been closed before care and before leaving the room, and the DON and Administrator stated staff should close window shades and privacy curtains during care and sit at eye level when assisting residents with feeding.
Failure to Provide SNF ABN Before End of Skilled Medicare Services
Penalty
Summary
The facility failed to issue a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) in writing at least two calendar days before the end of skilled Medicare services for two residents who remained in the facility after skilled coverage ended. Resident #43 discharged from skilled Medicare services on 01/16/26 and stayed in the facility, but there was no documentation that the resident or representative received a SNF ABN. Resident #100 discharged from skilled Medicare services on 11/11/25 and also remained in the facility, but there was no documentation that the resident or representative received a SNF ABN. The facility did not provide a policy regarding SNF ABN forms. During interviews, the Social Services Designee stated he/she was unaware that the SNF ABN form needed to be completed for residents who elected to stay in the facility, and the Administrator stated that residents who discharged from skilled Medicare services and remained in the facility should receive a SNF ABN.
Unsafe and Poorly Maintained Common Areas
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable homelike environment for residents. Survey observations of the nurse's station area showed a ceiling fan over the cafe area with a buildup of dirt and debris, two ceiling fans over the bird cage area with a buildup of dirt and debris and missing fan blades, and skylight outer edges over both the cafe area and the nurses' station with a buildup of dust and debris. In the main dining room, surveyors observed peeled paint near both double doors, a four-foot corner molding on the left side held together with two strips of medical tape, and a nickel-size hole in the wall above the handrail near the right-side double doors. Additional observations on the 200 hall showed several areas of exposed sheetrock and peeled paint behind the headboard of bed 2 by the window in one room, a missing corner piece of baseboard with exposed sheetrock and peeled paint by bed 1 near the door in the same room, three areas of peeled wallpaper on the left-side wall near another room, three feet of peeled wallpaper by a large canvas painting between two rooms, and two feet of peeled wallpaper by a brown-framed wooden picture near another room. Surveyors also observed an approximate four-inch by six-inch area of exposed sheetrock and peeled paint on the hallway wall below a cork-like bulletin board near the laundry room entrance. Review of the Maintenance Repair Log dated 11/01/25 through 01/21/26 showed no documentation of areas of concern addressed. Staff interviews indicated that repairs were expected to be written in the maintenance logbook at the nurse's station, with urgent issues reported directly to nursing or maintenance staff, and the Maintenance Supervisor stated he reviewed the logbook every other day but sometimes learned of needed repairs only in passing.
Missing transfer, discharge, and bed-hold notifications
Penalty
Summary
The facility failed to document, obtain signatures for, and send written notification to residents and/or their representatives regarding transfer or discharge to a hospital, including appeal rights and the name, address, or telephone number of the Office of the State Long Term Care Ombudsman, as well as the bed-hold policy information. The facility also did not provide a transfer/discharge policy. Review of the undated Bed Hold Guidelines showed that residents and/or their representatives were to be notified of bed-hold guidelines on admission, at the time of hospital transfer, and at the time of non-covered therapeutic leave, and that a signed authorization was required if the bed was to be held. For Resident #3, who was admitted on 08/26/25 and transferred to the hospital twice before returning to the facility, the Transfer/Discharge and Bed Hold Guidelines forms dated 09/09/25 and 09/24/25 showed no selected bed-hold preference, no daily bed-hold rate, no resident or representative signature, and no documentation that the information was provided in writing. Similar findings were identified for Resident #5, Resident #19, and Resident #34, whose records showed hospital transfers and returns, but whose forms also lacked a bed-hold choice, daily room rate, signature, and documentation of written notification. During interviews, the ADON, LPN, SSD, and Administrator described that the paperwork should be completed, signed when possible, and sent or mailed to the responsible representative, but the records reviewed did not show that this occurred for the four residents.
Infection Control Failures During Wound Care and Ice Chest Access
Penalty
Summary
The facility failed to ensure staff used acceptable infection control procedures during wound care for four residents. During observation of wound care for Resident #19, staff performed hand hygiene and put on gloves, but did not put on gowns before entering the room to provide treatment, even though EBP signage was posted and PPE was stored inside the room. During wound care for Resident #51, staff performed hand hygiene and put on gloves but did not put on gowns; the RN removed gloves, did not perform hand hygiene, left the room to get supplies, then returned without hand hygiene, put on gloves, and continued wound treatment. During wound care for Resident #1, the RN wore gloves, a mask, and a gown, but removed gloves, performed hand hygiene, left the room while still wearing the gown to get supplies and hygiene wipes, then returned without putting on a clean gown and continued wound treatment and incontinent care. During wound care for Resident #80, staff performed hand hygiene and put on gloves but did not put on gowns; the RN removed gloves, did not perform hand hygiene, left the room for supplies, then returned without hand hygiene, put on gloves, and continued wound treatment. Interviews with staff showed inconsistent understanding of gown use for residents on EBP. A CNA stated residents with wounds should have EBP signage and said a gown should have been worn during wound care but was forgotten. An LPN stated staff only wore gowns in rooms with an infection and did not wear gowns to provide wound treatment. The DON and ADON stated staff should perform hand hygiene before entering and after exiting a resident room, and that staff providing care for residents on EBP should remove the gown before exiting the room. The facility also failed to monitor ice chest carts to prevent resident and visitor access without staff assistance. One resident was observed opening an unmonitored ice chest cart, using the scoop, reaching into the ice with a bare hand, and scooping ice into a beverage container while no staff were present. Another resident’s visitor was observed taking the resident’s beverage container to the ice chest cart, opening it, using the scoop, reaching into the ice with a bare hand, and placing ice into the container while staff nearby did not intervene. The DON, ADON, and Administrator stated they would expect the ice chest to be removed, the ice discarded and refilled with fresh ice if a resident or visitor was witnessed using it other than staff, and that staff should sanitize their hands before entering and after exiting a resident’s room.
Misappropriation of Resident Funds by Bookkeeper
Penalty
Summary
The facility failed to protect the personal property and funds of 26 out of 27 sampled residents when a bookkeeper misappropriated a total of $20,110 from resident trust accounts and cash. The misappropriation occurred over several months, during which the bookkeeper used resident funds for personal use. Facility policy required that cash withdrawals from resident trust accounts be documented with detailed disbursement logs, including signatures from the resident, the bookkeeper, and a witness. However, the bookkeeper repeatedly failed to obtain the required witness signatures and labeled withdrawals as 'personal spending' without sufficient detail, in violation of facility policy. Multiple residents with moderate to severe cognitive impairment, including those with diagnoses such as dementia, schizophrenia, and intellectual disabilities, were affected. Interviews with these residents revealed that they did not request or receive cash withdrawals, despite their signatures appearing on disbursement logs. Several residents stated that the bookkeeper had them sign forms without explanation and that they did not receive any money. Staff interviews confirmed that these residents were not observed requesting or carrying cash, and that the bookkeeper was responsible for handling resident trust accounts and cash disbursements. Further review of facility records showed that the bookkeeper accepted cash deposits from resident representatives, issued receipts, but failed to deposit the funds into the appropriate accounts. In several cases, there were no records of deposits or account creation for residents who had provided funds, and receipts were not matched by corresponding entries in the trust accounts or petty cash logs. The bookkeeper had received training on proper procedures but did not follow them, resulting in the wrongful use of resident property and funds.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment, as evidenced by multiple observations of unsanitary and unsafe conditions. The designated smoking area was found to have dead insects, bird droppings, cigarette ashes, and scattered cigarette butts, along with a discarded N95 mask and a broom left against a column. Similar issues were noted in the courtyard, where cigarette butts were scattered on the ground. These conditions were observed over several days, indicating a lack of regular maintenance and cleaning. Inside the facility, the 500 Hall showed significant disrepair, including peeled wallpaper, missing outlet covers, exposed sheetrock, and a large hole in the wall. The dining room had dark scuff marks on the walls and missing trim, while the kitchen's dish return door had a large hole with missing sheetrock and trim. The 300 hallway had a buildup of grime on the floor, and the laundry room was cluttered with clothing, lint, grime, and stagnant water, along with missing drywall and peeled paint from water damage. Interviews with staff revealed a lack of clarity and responsibility regarding maintenance and cleaning duties. Housekeeping staff were unsure who was responsible for cleaning the smoking area, and the maintenance supervisor expected staff to report issues in a maintenance log, which was not consistently used. The floor technician, who was responsible for cleaning the smoking area and maintaining the grounds, was covering in the laundry department, leading to neglect in other areas. The administrator and maintenance supervisor both expressed expectations for a clean environment, but these were not met in practice.
Failure to Notify Residents of Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to residents and their representatives regarding transfers or discharges to a hospital. This deficiency was identified for four residents out of a sample of four, with a facility census of 80. The medical records of these residents showed multiple instances of hospital transfers without documented written notifications. For example, one resident was transferred to the hospital on two occasions, and another resident was transferred three times, yet there was no documentation of written notification for any of these transfers. Interviews with facility staff revealed a lack of adherence to the transfer/discharge notification process. The Assistant Director of Nursing indicated that nursing staff should complete a transfer/discharge form before a resident is transferred to the hospital, and a copy should be given to the Social Service Designee (SSD) for documentation. However, the Administrator acknowledged that these forms were not completed or maintained as required. The SSD admitted to not following up with the transfer/discharge forms for residents sent to the hospital, indicating a systemic issue in the facility's process for handling transfers and discharges.
Failure to Notify Residents of Bed Hold Policy
Penalty
Summary
The facility failed to notify residents and/or their representatives in writing of the bed hold policy at the time of transfer to the hospital for four residents. This deficiency was identified through interviews and record reviews, which revealed that there was no documentation of the bed hold policy being communicated in writing for Residents #7, #20, #46, and #279. Each of these residents had been transferred to the hospital on multiple occasions, yet there was no evidence that the facility provided the required written notification regarding the bed hold policy. Interviews with facility staff, including the Assistant Director of Nursing (ADON), the Administrator, and the Social Service Designee (SSD), confirmed that the bed hold policy forms were not being completed or maintained as required. The ADON indicated that nursing staff should fill out the bed hold policy form before a resident is transferred to the hospital, and a copy should be given to the SSD for documentation. However, the Administrator acknowledged that these forms were not being completed or kept, and the SSD admitted to not following up on the bed hold policy forms for residents transferred to the hospital.
Deficient Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to adequately document and manage pressure ulcers for two residents, leading to deficiencies in care. Resident #38, who was admitted with severe cognitive impairment and limited mobility, was at risk for pressure ulcers. Despite being identified as at moderate risk for skin breakdown, the facility did not have any documented orders for skin care related to the resident's left buttock. A skin assessment on 10/23/24 revealed an open area on the left buttock, but there was no documentation of the type, stage, measurements, or characteristics of the injury. Interviews with staff indicated a lack of awareness and documentation regarding the resident's skin condition, with the Director of Nursing only placing an order for skin prep after the issue was identified. Resident #46, also with severe cognitive impairment and dependent on staff for mobility, was at risk for pressure ulcers. The resident's medical record showed an order for skin prep to the heels, but there was no documentation of any skin conditions with specific details. Observations revealed a nickel-sized eschar on the right heel, yet the resident's heels were not floated as required, and heel protectors were not used consistently. Interviews with staff highlighted a lack of adherence to care plans and proper documentation, with the Assistant Director of Nursing acknowledging the need for weekly skin assessments with detailed measurements and staging. The facility's failure to document and manage pressure ulcers appropriately for these residents indicates a deficiency in following established protocols for pressure ulcer prevention and care. The lack of documentation and awareness among staff members contributed to inadequate care, as evidenced by the absence of detailed assessments and the inconsistent use of protective measures for residents at risk of skin breakdown.
Failure to Document Dialysis Communication
Penalty
Summary
The facility failed to provide adequate documentation of communication between the facility and the dialysis center for three residents requiring dialysis services. The facility's policy mandates that a Dialysis Communication Record be sent with residents on each dialysis visit, detailing care concerns, medications, and contact information. However, the review of the Dialysis Communication logs from July to October 2024 revealed numerous missed opportunities for completing these forms for Residents #6, #11, and #32. Resident #6, diagnosed with end-stage renal disease and dependent on renal dialysis, had orders for dialysis thrice weekly and required daily checks of the shunt for bruit and thrill. Despite these requirements, the facility failed to complete the Dialysis Communication forms consistently, missing all opportunities from July to September 2024 and most in October 2024. Similarly, Resident #11, with chronic kidney disease and other health issues, also had orders for dialysis thrice weekly and required checks of the AV fistula every shift. The facility again missed all opportunities to complete the communication forms from July to September 2024 and most in October 2024. Resident #32, with severe kidney damage and ESRD, also required dialysis thrice weekly and monitoring of the shunt site. The facility failed to complete the Dialysis Communication forms for all opportunities from July to September 2024 and most in October 2024. Interviews with staff and residents revealed inconsistencies in sending communication logs and checking for bruit and thrill, indicating a systemic issue in maintaining proper communication and documentation for residents undergoing dialysis.
Deficiency in Nurse Aide In-Service Education and Dementia Care Training
Penalty
Summary
The facility failed to conduct the required twelve hours of nurse aide in-service education per year and did not provide the necessary annual competencies in Dementia Care for two sampled nurse aides. The facility's assessment, revised in September 2024, outlined the requirements for in-service training, which included dementia management training and resident abuse prevention training. However, the facility did not have a policy in place for nurse aide in-service education, which contributed to the deficiency. Review of the in-service records from June 2023 to June 2024 showed that CNA C, hired on June 23, 2023, attended only nine hours and 30 minutes of in-services and did not complete the annual competency in Dementia Care. Similarly, CNA D, hired on July 11, 2023, attended only seven hours of in-services and also did not complete the required Dementia Care competency. Interviews with the Director of Nursing and the Administrator confirmed that nurse aides should receive 12 hours of education training annually, including Dementia Care, which was not met in these cases.
Resident Left Unsupervised Outside for Extended Period
Penalty
Summary
The facility failed to provide adequate supervision and implement its policy for missing residents, resulting in a resident being left outside for an extended period. On the night of 07/31/24, a resident with a history of amyotrophic lateral sclerosis, transient ischemic attack, depression, chronic kidney disease, high blood pressure, and diabetes mellitus type 2, went outside to pray and fell over a crack in the sidewalk. The resident was not accounted for until the following morning, despite staff noticing the resident's call light on and the room empty at 3:00 A.M. The staff did not initiate a search or follow the facility's Elopement-Missing Resident policy when the resident was first noticed missing. The resident was last seen by the Director of Nursing at approximately 11:30 P.M. on 07/31/24, and was not seen again until found outside at 8:15 A.M. on 08/01/24. During this time, the resident sustained multiple abrasions and was exposed to the elements for several hours. Interviews with staff revealed a lack of communication and action regarding the resident's absence. The Certified Medication Technician and Licensed Practical Nurse did not take immediate action to locate the resident, and the Director of Nursing was not informed of the resident's absence until much later. The facility's failure to account for the resident and initiate a timely search led to the resident being found with injuries and requiring hospital evaluation.
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Illustrative
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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 De Soto
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stonebridge Desoto | 4.2 mi | ★★★★★ | 0 | 0 |
| Baisch Nursing Center | 6.5 mi | ★★★★★ | 0 | 0 |
| Superior Manor Of Festus, Llc | 8.8 mi | ★★★★★ | 0 | 0 |
| Festus Manor | 9.4 mi | — | 0 | 0 |
| Crystal Oaks | 9.6 mi | ★★★★★ | 4 | 0 |
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