Not rated by CMS — ratings are suppressed for new or low-volume facilities.
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 Hillcrest Care Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairments was allegedly abused by a nursing assistant, who reportedly placed a washcloth over the resident's mouth. The incident, initially reported in August, was not investigated or reported to the state agency. The issue resurfaced in January through a group text message, but no action was taken by the DON or ADM, despite the facility's policy requiring immediate investigation and reporting.
The facility failed to attempt a Gradual Dose Reduction (GDR) and/or have a documented contraindication for three residents' psychotropic medications. One resident on Escitalopram had no GDR attempts since 8/31/21, another on Cymbalta had no GDR review from 4/23/23 to 4/25/24, and a third on Lorazepam had no GDR review from 4/23/23 to 4/24/24.
The facility failed to employ a qualified Dietary Manager as required by their job description and licensure regulations. The current DM did not possess the necessary certification, which was confirmed by the facility Administrator. This deficiency had the potential to affect all 17 residents who consumed food from the kitchen.
A facility failed to ensure a call light was within reach for a resident requiring assistance with activities of daily living. Despite multiple observations showing the call light out of reach, staff did not rectify the situation, compromising the resident's ability to request necessary help.
The facility failed to provide a resident or their representative with the required bed hold information when the resident was transferred to the hospital for heart failure and aspiration pneumonia. The Administrator confirmed the lack of documented evidence for this notification.
A facility failed to check the placement of a feeding tube for a resident before administering medications and starting a feeding, contrary to physician orders and facility policy. The LPN confirmed the oversight during an interview.
A facility failed to ensure medications were given as ordered, resulting in a 7.14% medication error rate. An LPN crushed and administered medications without a physician's order, including medications that should not be crushed. The facility's policies on medication administration and errors were not followed.
The facility staff failed to follow a recipe when preparing pureed foods for a resident on a pureed diet. The dietary cook prepared pureed pork and beans without using a recipe or measuring portion sizes, and provided only this item to the resident. The registered dietician confirmed that a recipe should have been available and used.
Failure to Investigate and Report Alleged Abuse
Penalty
Summary
The facility failed to investigate and report an allegation of abuse involving a resident with severe cognitive impairments. The resident, who required extensive assistance with daily activities and had significant memory problems, was allegedly subjected to abuse by a nursing assistant who reportedly placed a washcloth over the resident's mouth. This incident was initially reported in August 2024 but was not investigated or reported to the state agency as required by the facility's policy. The deficiency was further highlighted when the allegation resurfaced in a group text message in January 2025, which included the night shift staff, the Director of Nursing (DON), and the Administrator (ADM). Despite this, no investigation was conducted, and the allegation remained unreported. Interviews with staff confirmed that the DON and ADM were unaware of the incident until the group text message, and the facility's policy mandates immediate investigation and reporting of such allegations, which was not adhered to.
Failure to Attempt Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
The facility failed to attempt a Gradual Dose Reduction (GDR) and/or have a documented contraindication for three residents' psychotropic medications. Resident 2, who had dementia and depression, was on Escitalopram since 6/1/21. The physician refused a GDR on 8/31/21, and there was no evidence of further attempts or documented contraindications for GDR after that date. The facility administrator confirmed the lack of evidence for GDR attempts or contraindications during an interview on 4/30/24. Resident 4, admitted with diagnoses including diabetes, heart failure, chronic pain syndrome, and major depressive disorder, had an order for Cymbalta since 5/27/21. There was no evidence of a GDR review by the consultant pharmacist or the resident's physician from 4/23/23 to 4/25/24. Similarly, Resident 6, who had insomnia, chronic pain, anxiety disorder, dementia, and depression, was on Lorazepam. There was no evidence of a GDR review by the consultant pharmacist or the resident's physician from 4/23/23 to 4/24/24. The DON confirmed the lack of GDR reviews for both residents during interviews on 5/1/24 and 5/2/24, respectively.
Facility Lacks Qualified Dietary Manager
Penalty
Summary
The facility failed to employ a qualified Dietary Manager (DM) as required by their job description and licensure regulations. The job description for the DM role specified that the individual must have completed a Dietary Manager certification course. However, a review of the staff list revealed that the current DM did not possess the necessary certification. This was confirmed during an interview with the facility Administrator, who acknowledged that the current DM did not meet the required qualifications. This deficiency had the potential to affect all 17 residents who consumed food from the kitchen, with a total sample size of 10 residents being reviewed.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure a call light was within reach for a resident who required assistance with activities of daily living. The resident, who had diagnoses including heart failure, arthritis, Chronic Obstructive Pulmonary Disease, malnutrition, and dysphagia, required substantial to maximal assistance with personal and toileting hygiene, and partial to moderate assistance with dressing, bed mobility, and transfers. The resident was also frequently incontinent of bowel and bladder. During multiple observations on the same day, the resident was seen seated in a recliner with the call light attached to the bed and out of reach. Despite the resident's need for assistance, the call light remained out of reach throughout the day, even after a Licensed Practical Nurse (LPN) entered the room and did not ensure the call light was accessible before leaving. An interview with the LPN confirmed that the resident required assistance with transfers, mobility, and toileting and used the call light to seek staff assistance. The Director of Nursing (DON) also confirmed that the resident required staff assistance with activities of daily living and that call lights should always be within reach for residents to call for help when needed. The failure to ensure the call light was within reach compromised the resident's ability to request necessary assistance, leading to the identified deficiency.
Failure to Provide Bed Hold Information
Penalty
Summary
The facility failed to provide Resident 10 or the resident's representative with the required bed hold information when the resident was transferred to the hospital. According to the facility's Bed Hold Prior to Transfer Policy, written information regarding bed hold policies must be given to the resident or their representative prior to transferring a resident to the hospital or during therapeutic leave. This information should include the duration of the state bed-hold, the reserve bed payment policy, the facility policy regarding bed-hold periods, and the conditions upon which the resident would return to the facility. However, a review of Resident 10's medical record from the period of hospitalization revealed no evidence that such information was provided. Resident 10 was admitted to the hospital for heart failure and aspiration pneumonia. The resident's nursing progress notes indicated the hospitalization occurred from 3/15/24 to 3/27/24. During an interview, the Administrator confirmed that there was no documented evidence that the required bed hold information was provided to Resident 10 or their representative during this period. The facility census at the time was 17, and the sample size for this review was 1.
Failure to Check Feeding Tube Placement
Penalty
Summary
The facility failed to check the placement of a feeding tube for Resident 10, which is necessary to prevent potential complications. The Care and Treatment of Feeding Tubes Policy required that tube placement be verified before beginning a feeding and before administering medications. Additionally, the enteral retention device was to be checked daily to ensure it was properly approximated to the abdominal wall and that the surrounding skin was intact. The physician's order for Resident 10 specified that the staff should check the gastric residual before administering medications, flushing the feeding tube, and starting a feeding. If the residual was greater than 100 cc, the feeding was to be held. On the observed date, LPN-A administered Resident 10's routine medications and initiated the resident's bolus feeding without checking the placement of the feeding tube or assessing the gastric residual. This action was in direct violation of the physician's order and the facility's policy. During an interview, LPN-A confirmed the failure to check the tube placement and acknowledged that the feeding should have been held if the gastric residual was greater than 100 cc.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure medications were given as ordered, resulting in a medication error rate of 7.14 percent, which exceeds the acceptable threshold of 5 percent. During an observation, an LPN crushed and administered several medications in applesauce for a resident without a physician's order to crush the medications. Notably, the medications Ziprasidone and Ferrous Sulfate, which should not be crushed according to the Physician's Desk Reference, were administered in this manner. The resident's Medication Administration Record (MAR) indicated that the resident took medications in applesauce, but there was no evidence of an order to crush the medications. The facility's policies on medication administration and medication errors were not followed, as medications were not administered according to physician's orders, manufacturer's specifications, or accepted standards of practice. Interviews with the facility Administrator and the Director of Nursing confirmed that medications requiring crushing should have a doctor's order and be reviewed by a pharmacist to ensure safety. The failure to adhere to these protocols led to the observed medication errors and the elevated error rate.
Failure to Follow Recipe for Pureed Foods
Penalty
Summary
The facility staff failed to follow a recipe when preparing pureed foods for a resident on a pureed diet. The noon meal menu included lasagna, Caesar salad, garlic toast, and pumpkin dessert, but the dietary cook instead prepared pureed pork and beans without using a recipe or measuring portion sizes. The cook added an unmeasured amount of pork-based bouillon/paste to the mixture and provided only the pureed pork and beans to the resident, who had requested it. The registered dietician confirmed that a recipe should have been available and used for preparing pureed food items.
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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 Laurel
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Park View Haven Nursing Home | 8.5 mi | ★★★★★ | 10 | 0 |
| Wayne Countryview Care And Rehabilitation | 13.1 mi | ★★★★★ | 8 | 0 |
| Colonial Manor Of Randolph | 14.2 mi | ★★★★★ | 13 | 0 |
| Wakefield Health Care Center | 15.3 mi | ★★★★★ | 0 | 0 |
| Accura Healthcare Of Hartington | 16.4 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.