Average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hillcrest Center during CMS and state inspections, most recent first.
The facility failed to maintain an effective pest control program, as evidenced by repeated pest control service reports documenting mouse activity in staff areas, multiple resident rooms, therapy areas, and common spaces, along with ongoing use of traps and glue boards. Several residents and a resident’s family reported seeing mice in resident rooms and noted structural gaps in baseboards and near heating/air conditioning units that could allow rodent entry. During a tour, surveyors observed mouse droppings in specific resident rooms on the first floor and a hole in a baseboard, while staff from various departments, including kitchen staff, NAs, and licensed staff, confirmed rodent sightings on multiple floors and near the kitchen hallway, even though no droppings were seen in the kitchen or dry storage at the time of observation.
A resident with severe cognitive impairment was verbally abused by a nursing assistant, as witnessed by a cognitively intact roommate. The incident was reported to an LPN, but the LPN failed to immediately notify a supervisor as required by facility policy. Documentation later confirmed both the abuse and the failure to report it promptly.
The facility failed to meet the required minimum nurse aide staffing ratios on several occasions due to call outs from inclement weather and illness, resulting in unfilled slots. This deficiency was observed on multiple days, with the facility not maintaining the mandated staffing levels of one NA per 10 residents during the day shift, one NA per 11 residents during the evening shift, and one NA per 15 residents during the night shift.
The facility did not meet the required 3.2 hours of direct resident care per resident on nine days, with staffing hours ranging from 2.94 to 3.16. This was confirmed by facility administration.
The facility failed to ensure nursing staff had the necessary competencies for PICC line care, as evidenced by missing documentation of required dressing changes and assessments for a resident. Two registered nurses lacked documented competencies for PICC line management, and the Director of Nursing could not provide this documentation during the survey.
The facility failed to maintain an effective infection control program, as evidenced by a nurse aide entering a COVID-19 positive resident's room without proper PPE and improper catheter care for a resident. Additionally, infection surveillance logs were incomplete, lacking essential details such as infection type and symptoms.
The facility failed to maintain an effective antibiotic stewardship program, lacking protocols and a monitoring system for antibiotic use over five months. Documentation from March to June 2024 showed missing symptom records, stop dates, and reviews for antibiotic appropriateness. The Infection Preventionist confirmed these deficiencies, violating facility policies and CDC guidelines.
The facility did not provide mandatory training on its QAPI program to four staff members, including LPNs and Nurse Aides, as required. This deficiency was confirmed with the DON, highlighting a failure in staff development and management responsibilities.
A resident in an LTC facility missed doses of Oxycodone and Ciprofloxacin due to errors in medication administration. The resident, who was cognitively intact and had a recent urinary tract infection, reported missing Oxycodone doses after the order was discontinued. The Director of Nursing confirmed the error. Additionally, the resident missed three doses of Ciprofloxacin, confirmed by the Regional RN, as the pills were still in the medication bubble pack.
A facility failed to provide adequate care for a resident with a PICC line, as required by professional standards. The facility's policy mandated regular measurements of the upper arm circumference and external catheter length, but these were not documented on several occasions. The DON confirmed that the necessary dressing changes and assessments were not completed as ordered by the physician, indicating a breach in the facility's protocols.
A resident with multiple health conditions did not receive a prescribed K2 Plus D3 oral tablet consistently due to the facility's failure to ensure timely availability of the medication. The medication was not administered on several occasions due to it being on back order or on hold, with no documented reason for some dates. The Director of Nursing was unaware of the reasons for the medication's unavailability.
The facility failed to adequately monitor the use of psychotropic medications for two residents, leading to a deficiency in ensuring drug regimens were free from unnecessary drugs. Despite having care plans that required monitoring for side effects and efficacy, there was no evidence of ongoing monitoring for the prescribed medications. An interview with the Infection Preventionist confirmed the need for such monitoring, highlighting the facility's failure to adhere to its medication management policy.
Failure to Maintain Effective Rodent Control Throughout Facility
Penalty
Summary
The facility failed to maintain an effective pest control program to keep the building free of rodents, despite having a policy that assigns responsibility for a pest-free environment through contracted pest control services on a periodic basis. Review of pest control service reports showed ongoing and repeated interventions for rodent activity throughout the facility, including placement of snap traps in a staff bathroom, identification of rodent feces near vending machines, and capture of a mouse in the maintenance office. Documentation also showed rodent activity in multiple resident rooms, the third-floor therapy area, and other common areas, with repeated replacement of glue boards and snap traps, indicating persistent rodent concerns across various locations. Interviews and observations further confirmed active rodent presence in resident care areas. Two of eight alert and oriented residents reported seeing mice in their rooms, and family members of a resident reported observing mice in that resident’s room, providing photographs and identifying structural deficiencies such as holes in baseboards and near the heating/air conditioning unit that could allow rodent entry. During a facility tour, mouse droppings were observed in specific first-floor resident rooms, including on the floor near windows, on top of heating/air conditioning units, and behind a headboard, along with a visible hole in a baseboard along a bathroom wall. Staff interviews across multiple floors, including first-floor staff, kitchen staff, nurse aides, and licensed staff, confirmed sightings of mice in resident areas and in the hallway adjacent to the kitchen, demonstrating that rodent activity was occurring in multiple parts of the facility.
Failure to Immediately Report Resident Abuse Allegation
Penalty
Summary
Facility staff failed to immediately report an allegation of verbal and physical abuse involving a resident with severe cognitive impairment. According to the facility's abuse prohibition policy, all allegations of abuse must be reported immediately, investigated, and documented, with the administrator responsible for reporting to local authorities within 24 hours. On the date in question, a cognitively intact resident, who shared a room with the affected resident, witnessed a nursing assistant using foul and racially abusive language toward the resident with memory problems. The witness reported the incident to the licensed nurse responsible for their care during the shift. Despite this report, the licensed nurse did not immediately notify the supervisor on duty about the alleged abuse. Documentation later submitted to the Department of Health confirmed that the nursing assistant verbally abused the resident and that the nurse neglected to report the incident as required by policy. The resident who was the subject of the abuse was noted to have severe cognitive impairment but no physical limitations, and was ambulatory with supervision and a walker.
Failure to Meet Minimum Nurse Aide Staffing Ratios
Penalty
Summary
The facility failed to meet the required minimum nurse aide (NA) staffing ratios on several occasions, as evidenced by document review and staff interviews. Specifically, the facility did not maintain the mandated staffing levels of one NA per 10 residents during the day shift, one NA per 11 residents during the evening shift, and one NA per 15 residents during the night shift. This deficiency was observed on multiple days across December 2024, January 2025, and February 2025. For instance, on December 27, 2024, the day shift had 15 NAs for 169 residents, falling short of the required 16.9 NAs. Similarly, on January 18, 2025, the night shift had only 6 NAs for 171 residents, whereas the minimum required was 11.27 NAs. During an interview with the Nursing Home Administrator and Director of Nursing on February 12, 2025, it was revealed that the facility did not intentionally staff below the minimum requirements. However, they experienced challenges in maintaining staffing levels due to call outs caused by inclement weather and illness, which resulted in unfilled open slots. This situation led to the facility's inability to meet the regulatory staffing requirements on the specified dates.
Plan Of Correction
1. All residents received care in accordance with their plan of care and attending physician orders. 2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs, the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. The facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff. 3. All Nursing Staff have been educated on the 7/1/2024 Nursing Ratios and PPD requirements and the importance of maintaining the schedule as posted. 4. To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly for 4 weeks, then monthly for two months. Results will be taken to the QAPI for review and revision as needed.
Deficiency in Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct resident care per resident in a 24-hour period on nine out of twenty-one sampled days. This deficiency was identified through a review of the facility's nursing staffing sheets for specific weeks between December 2024 and February 2025. On the identified days, the facility's staffing hours fell below the required threshold, with recorded hours ranging from 2.94 to 3.16. The facility administration confirmed the failure to meet the nursing hour requirements during an interview conducted on February 12, 2025.
Plan Of Correction
1. All residents received care in accordance with their plan of care and attending physician orders. 2. The Clinical Leadership Team and scheduler review the schedule daily. In the event of call offs, the facility follows staffing policies including exhausting all possible replacements from internal staffing pool and contracted agency staff. The facility continues to offer incentives, coordinate staffing schedules, and replace call-offs per policy while actively continuing to hire for all open positions and additional pool staff. 3. All Nursing Staff have been educated on the 7/1/2024 Nursing Ratios and PPD requirements and the importance of maintaining the schedule as posted. 4. To monitor and maintain ongoing compliance, the DON or designee will audit staffing weekly x4 weeks then monthly for two months. Results will be taken to the QAPI for review and revision as needed.
Deficiency in PICC Line Care Competency
Penalty
Summary
The facility failed to ensure that nursing staff possessed the appropriate competencies and skill sets related to the care of residents with PICC lines. Specifically, two employees, identified as E8 and E9, did not have documented competencies for PICC line care and management. This deficiency was identified during a review of clinical records, facility documentation, and staff interviews. The Director of Nursing was unable to provide the requested competency documentation for these employees during the survey. The deficiency was further evidenced by the case of Resident R137, who had a PICC line in the right upper extremity. The resident's treatment administration record (TAR) showed no documented evidence of required dressing changes and assessments on multiple dates in June and July 2024, as ordered by the physician. The lack of documentation indicated that the necessary PICC line care, including dressing changes and assessments of external catheter length and arm circumference, was not completed as required.
Inadequate Infection Control and Surveillance in LTC Facility
Penalty
Summary
The facility failed to establish an effective infection control program, particularly in infection surveillance, catheter care, and the use of personal protective equipment (PPE) with transmission-based precautions. Observations revealed that a nurse aide, Employee E4, entered a room of a resident with confirmed COVID-19 without wearing the required PPE, which included a gown, face shield, and gloves, despite signage indicating the need for such precautions. This lapse in protocol was confirmed by a licensed nurse, Employee E5, who acknowledged the necessity of full PPE for entering the room of a COVID-19 positive resident. Additionally, the facility's catheter care practices were found to be inadequate. Observations showed that Resident R163's catheter bag was placed directly on the floor, contrary to the facility's policy that requires catheter bags to be kept off the floor to prevent infection. This improper placement was confirmed by Employee E5, who acknowledged the deviation from the established protocol. The facility's infection surveillance logs from March to June 2024 were incomplete, lacking critical information such as infection type, organism identification, and signs and symptoms for numerous cases. This deficiency in documentation was confirmed by the Infection Preventionist, Employee E7, who admitted the logs were incomplete. The lack of comprehensive infection surveillance data indicates a failure to effectively monitor and manage infections within the facility.
Deficiency in Antibiotic Stewardship Program
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program over a five-month period, as evidenced by a lack of antibiotic use protocols and a system to effectively monitor antibiotic usage. The facility's policy, dated August 7, 2024, required the implementation of an Antibiotic Stewardship Program (ASP) that included antibiotic use protocols and systems for monitoring antibiotic use. However, the facility did not adhere to these requirements, as confirmed by the Infection Preventionist during an interview. Throughout the months of March to June 2024, the facility's documentation revealed significant gaps in the monitoring and documentation of antibiotic use. In March, all 11 antibiotic orders lacked documented symptoms on the infection surveillance tool, and there was no record of stop dates, total days of therapy, outcomes, or adverse events. Similar deficiencies were noted in April, May, and June, with a consistent absence of symptom documentation and no antibiotic review to determine the appropriateness of usage. The facility's failure to document and review antibiotic use was further corroborated by the Infection Preventionist, who confirmed the absence of use protocols and an effective monitoring system. This lack of compliance with the facility's own policies and CDC guidelines for antibiotic stewardship resulted in a deficiency under 28 Pa. Code 211.10(d) and 28 Pa. Code 211.12(d)(1)(5).
Lack of QAPI Training for Staff
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) program included mandatory training for staff on the elements and goals of the program. This deficiency was identified through a review of the education records of four employees, including two Licensed Practical Nurses and two Nurse Aides, which revealed no evidence of training related to the facility's QAPI program. The findings were confirmed with the Director of Nursing, indicating a lack of compliance with the required staff development and management responsibilities as outlined in the relevant Pennsylvania Code sections.
Medication Administration Errors for Resident
Penalty
Summary
The facility failed to ensure medications were administered per physician orders for a resident, identified as R68. The resident, who was cognitively intact and had a recent diagnosis of a urinary tract infection, reported missing doses of Oxycodone, an opioid medication prescribed for chronic pain. The medication was discontinued on July 23, 2024, and the resident did not receive it on July 24 and the morning of July 25, 2024. The medication was re-ordered on July 25, 2024, and the resident received the evening dose that day. The Director of Nursing confirmed there was an error in the medication ordering process, resulting in the missed doses. Additionally, the resident had a physician order for Ciprofloxacin, an antibiotic for treating urinary tract infections, to be administered twice daily for 14 days starting July 14, 2024. The medication administration record showed that the evening doses on July 19, 21, and 25, 2024, were not signed out as administered. This was confirmed by the Regional Registered Nurse, who observed that the pills were still in the medication bubble pack, indicating the doses were missed.
Failure to Adhere to PICC Line Care Protocols
Penalty
Summary
The facility failed to provide adequate treatment and care for a resident with a Peripherally Inserted Central Line Catheter (PICC) in accordance with professional standards of practice. The facility's policy required the measurement of the upper arm circumference and the external length of the PICC catheter at insertion, with each dressing change, and when clinically indicated. However, observations and reviews of clinical records revealed that the dressing change and necessary assessments were not completed as ordered by the physician for Resident R137. Specifically, there was no documented evidence of dressing changes or assessments on several dates in June and July 2024. The Director of Nursing confirmed that the PICC line dressing change, assessment, and monitoring were not completed for the resident as ordered by the physician and according to the facility protocol. This deficiency was identified through observations, clinical record reviews, and interviews with staff, highlighting a failure to adhere to the facility's policies and procedures for PICC line care. The report cites specific Pennsylvania Code regulations related to resident care policies and nursing services that were not followed.
Medication Availability Deficiency for Resident
Penalty
Summary
The facility failed to ensure timely availability of a prescribed medication for a resident, identified as Resident R135, who has multiple health conditions including diabetes, obesity, chronic kidney disease, hypertension, and vitamin D deficiency. The resident was prescribed a K2 Plus D3 oral tablet to be administered once weekly on Saturdays. However, the medication was not consistently available, leading to missed doses on several occasions. Specifically, the medication was not administered on March 2, March 23, March 30, April 6, and April 13, 2024, due to it being on back order or on hold, with no documented reason for some of these dates. Interviews and record reviews revealed that the resident reported not receiving the vitamin supplement regularly because the facility frequently ran out of it. The Director of Nursing was unaware of the reasons for the medication's unavailability from the pharmacy. The medication was eventually discontinued for the remaining dates in April 2024 due to its unavailability. This deficiency was identified under the Pennsylvania Code sections related to pharmacy services, resident care policies, and nursing services.
Inadequate Monitoring of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that the drug regimens of two residents were free from unnecessary drugs, specifically related to the use of antipsychotic medications without adequate monitoring. The facility's policy on medication management requires that each resident's drug regimen be reviewed to ensure it is free from unnecessary drugs, including those without adequate monitoring. However, the clinical records for Resident R45 and Resident R29 revealed a lack of evidence that the facility conducted ongoing monitoring of the side effects, adverse consequences, and efficacy of the psychotropic medications prescribed to them. Resident R45 had orders for Clonazepam for anxiety and Trazodone for depression and insomnia. Despite having a care plan that included monitoring for changes in mental status and functional level, there was no evidence of ongoing monitoring for the side effects and efficacy of these medications. Similarly, Resident R29 was prescribed multiple medications, including Divalproex Sodium for substance abuse disorder, Lorazepam for anxiety, Mirtazapine for poor appetite and depression, Quetiapine Fumarate for schizophrenia, and Trazodone for anxiety and schizoaffective disorder. The care plan for Resident R29 also included interventions for behavior monitoring and side effects, but the clinical record lacked evidence of ongoing monitoring. An interview with Employee E7, the Infection Preventionist, confirmed that residents on psychotropic drugs should have orders to monitor side effects and adverse effects, with staff documenting findings on an ongoing basis. The facility's failure to adhere to its medication management policy and ensure adequate monitoring of psychotropic medications resulted in a deficiency related to the unnecessary use of drugs for these two 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 Wyncote
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hopkins Center | 0.3 mi | ★★★★★ | 26 | 0 |
| Wyncote Care Center | 0.4 mi | ★★★★★ | 12 | 0 |
| York Nursing And Rehabilitation Center | 1.6 mi | ★★★★★ | 17 | 1 |
| Ivy Hill Post Acute Nursing & Rehabilitation Llc | 1.8 mi | ★★★★★ | 19 | 0 |
| Edgehill Nursing And Rehab Cen | 1.9 mi | ★★★★★ | 12 | 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.