Pennsylvania Department of Health
 HILLCREST CENTER
Patient Care Inspection Results

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HILLCREST CENTER
Inspection Results For:

There are  151 surveys for this facility. Please select a date to view the survey results.

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HILLCREST CENTER - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:Based on an Abbreviated Survey in response to four complaints completed June 30, 2026, it was determined that Hillcrest Center was not in compliance with the following Requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations related to the health portion of the survey process.


 Plan of Correction:


483.10(g)(14)(i)-(iv)(15) REQUIREMENT Notify of Changes (Injury/Decline/Room, etc.):This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.10(g)(14) Notification of Changes.
(i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is-
(A) An accident involving the resident which results in injury and has the potential for requiring physician intervention;
(B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications);
(C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or
(D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii).
(ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician.
(iii) The facility must also promptly notify the resident and the resident representative, if any, when there is-
(A) A change in room or roommate assignment as specified in §483.10(e)(6); or
(B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section.
(iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident
representative(s).

§483.10(g)(15)
Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c)(9).
Observations: Based on review of facility policy, review of clinical record, review of facility documentation, and staff interview, it was determined that the facility failed to notify the resident representative of a transfer to the hospital for one of one resident reviewed for notification of changes (Resident R1). Findings include: Review of facility policy titled "Discharge and Transfer" last revised June 11, 2026, revealed the facility is required to immediately inform the resident and residents representative when a decision is made to transfer the resident. Further, the policy states that when immediate transfers are required due to the residents' urgent medical needs, notification must be provided as soon as practicable. Review of resident R1's clinical record revealed that the resident was transported to his/her scheduled outpatient dialysis treatment on June 19, 2026, and subsequently required a transfer to the hospital, for further evaluation. Further review of Resident R1's clinical record revealed no documented evidence Resident R1's representative, Power of Attorney (POA - legal tool that grants an individual the authority to make decisions and take actions on behalf of another person), was notified of the hospital transfer. Review of Resident R1's clinical record revealed a nursing progress noted June 19, 2026, at 6:04 PM documenting the resident was transported to his/her scheduled hemodialysis treatment via medical transport. During the dialysis treatment, the dialysis center notified the facility that Resident R1 had been transferred to the hospital due to left Arteriovenous Fistula complication (An AV Fistula is a surgically created connection between an artery and an and a vein that provides vascular access for hemodialysis. Complicate complications may include clotting, bleeding, infection, poor blood flow or malfunction which can interrupt dialysis treatment and require urgent medical evaluation). The nurse's note further documented that facility staff contacted the hospital and confirmed the resident had been admitted for evaluation and treatment of the left AV fistula. Review of facility documentation revealed Resident R1's representative became aware of the transfer only after arriving at the facility approximately two days later (June 21, 2026) to visit the resident, at which time staff informed Resident R1's representative that the resident had been transferred to the hospital on June 19, 2026. Interview with Nursing Home Administrator, Employee E1, on June 30, 2026, at approximately 10:00 AM revealed he/she was covering the facilities front desk on June 21, 2026, when the Resident R1's representative arrived to visit the resident. Nursing Home Administrator, Employee E1, explained it was at that time when Resident R1's representative was notified the resident had been transferred to the hospital two days ago, on June 19, 2026. Continued interview with Nursing Home Administrator, Employee E1, on June 30, 2026, at 10:00 a.m. confirmed Resident R1's representative was not notified of the resident's hospital transfer prior to his/her arrival at the facility on June 21, 2026. 28 Pa. Code 201.14 (a) Responsibility of licensee. 28 Pa. Code 211.12 (d)(3) Nursing services
 Plan of Correction - To be completed: 07/14/2026

Resident R1 Responsible Party(RP)/POA has been notified of transfer to the ER from the dialysis center.
1. DON/Designee completed an initial audit of residents with unplanned transfers to the ER for the previous 7 days to ensure RP/POA notified of unplanned transfer to ER.
2. NPE/designee will re-educate Nursing management and licensed nurses to ensure residents with an unplanned transfer to the ER are communicated to the RP/POA.
3. DON/designee will conduct weekly audits X4, then monthly X2 to ensure RP/POA has been notified of unplanned transfer to the ER.
4. DON/designee will review results of audits with the QAPI committee monthly X 3.

483.25 REQUIREMENT Quality of Care:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:
Based on review of clinical records, and staff interview it was determined that the facility failed to ensure care and services were provided in accordance with physician orders for one of one resident reviewed (Resident R1).


Findings include:

Review of Resident R1's discharge MDS (minimum data set - federally mandated resident assessment and care screening) dated June 19, 2026, revealed the resident was discharged to a short-term acute care hospital. Per the MDS, Resident R1 has a diagnosis of end stage renal disease (also known as kidney failure) and receives hemodialysis (a machine used to physically filter waste out of the blood).

Review of Resident R1's physician orders revealed an order dated October 21st, 2025, directing staff not to obtain blood pressure measurements in resident's left arm.

Review of Resident R1's clinical record revealed vital signs of documented blood pressure measurements that are repeatedly obtained in the resident's left arm on the following dates:

6/4/2026: BP (blood pressure) 137/76 left armBP 97/66 left arm
6/11/2026: BP 150/68 left arm
6/11/2026: BP 110/65 left arm
6/14/2026: BP 138/77 left arm
6/16/2026: BP 143/76 left arm
6/16/2026: BP 102/66 left arm
6/18 /2026: BP 117/63 left arm
6/18/2026: BP 105/54 left arm
6/26/2026: BP 148/72 left arm
6/27/2026: BP 137/76 left arm

Interview on June 30, 2026, at approximately 2:00 p.m. with Nursing Home Administrator, Employee E1, and Director of Nursing, Employee E2, confirmed that staff was documenting blood pressure readings from Resident R1's left arm despite a physician order directing staff not to.

28 Pa. Code 211.10 (c) Resident care policies.

28 Pa. Code 211.12 (d)(5) Nursing Services.





 Plan of Correction - To be completed: 07/14/2026

1. Resident R1 had no adverse effect, blood pressures being obtained in the nonaffected arm per physician order.
2. DON/Designee completed an initial audit of current residents receiving dialysis with orders for blood pressure measurements in a specific arm.
3. NPE/designee will re-educate licensed nurses on obtaining blood pressures on specific arm per physician orders.
4. DON/designee will conduct weekly audits X4, then monthly X2 on residents receiving dialysis with orders for blood pressure measurements in a specific arm.
DON/designee will review results of audits with the QAPI committee monthly X 3. Audits will continue, if identified as necessary.

483.20(f)(5),483.70(h)(1)-(5) REQUIREMENT Resident Records - Identifiable Information:This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.
§483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

§483.70(h) Medical records.
§483.70(h)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

§483.70(h)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

§483.70(h)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

§483.70(h)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

§483.70(h)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.
Observations:
Based on review of facility policy, review of facility documentation, review of clinical records, and staff interview it was determined that the facility failed to maintain complete and accurate documentation one of two residents reviewed (Resident R1).


Findings include:

Review the facility policy titled "Dialysis Hemodialysis Communication and Documentation" last revised November 14, 2025, revealed the facility is responsible for maintaining ongoing communication and collaboration with the certified dialysis facility regarding the resident condition before and after each hemodialysis treatment the policy requires. A licensed nurse to complete the hemodialysis communication record including the pre dialysis evaluation before the resident leaves for dialysis. The dialysis facility to complete and return the communication form with the resident following treatment. Upon the resident return, a licensed nurse to review the dialysis facilities communication, assess the resident, and complete the post dialysis treatment evaluation. If the dialysis communication form is not returned, the facility must contact the dialysis center, request the information and document that communication.

Review of facility dialysis service agreement between the facility and the contracted dialysis provider revealed the agreement requires ongoing communication and coordination of care between both parties. The agreement states the dialysis center will provide the facility with information regarding the resident's dialysis treatment fully and aspects of the resident's care related to the provision of the dialysis service. The agreement also requires the facility to ensure all pertinent medical information accompanies the resident to dialysis, including the resident's medical history, current treatments, medication changes, changes in condition, diet, fluid restrictions, laboratory findings, advanced directives, and any additional information necessary to facilitate coordination of care. The dialysis provider is required to maintain reports of services rendered, and the facility has the right to obtain copies of these records for inclusion in the resident's medical records to ensure continue the of care

Review of resident R1's discharge Minimum Data Set (MDS - federally mandated resident assessment and care screening) date of June 19, 2026, revealed Resident R1 was discharged to a short-term acute care hospital. Per the MDS, Resident R1 has a diagnosis of end stage renal disease (also known as kidney failure) and receives hemodialysis (machine that filters the toxins from the blood) treatment.

Review of Resident R1's dialysis communication records revealed incomplete and inconsistent documentation, including missing post dialysis vital signs, post dialysis weights and post treatment assessments. In addition, discrepancies were identified between the dialysis communication record and the documentation in the resident's electronic medical record.

Continued review of Resident R1 hemodialysis communication record revealed the facility failed to consistently complete the required post dialysis nursing assessment upon the resident's return to the facility on the following dates:

June 5, 2026, the post hemodialysis section to be completed by the facilities licensed nurse was not completed

June 8, 2026, the post hemodialysis assessment section was not completed.

June 10, 2026, the post hemodialysis assessment section was not completed.

June 12, 2026, the post hemodialysis assessment section was not completed.

June 17, 2026, neither the section to be completed by the certified dialysis nurse allowing treatment nor the post hemodialysis section to be completed by the facility licensed nurse was completed.

June 26, 2026, the post hemodialysis assessment section to be completed by the facility's licensed nurse was not completed.

Further review of Resident R 1's clinical record revealed the documented vital signs in the electronic medical record did not consistently correspond with the vital signs documented in the resident dialysis communication binder. Comparison of the two records identified discrepancies in the documented vital signs, as well as missing documentation in both the electronic record and the dialysis communication binder cord.

Interview with Licensed Nurse, Employee E3, on June 30th, 2026, at approximately 1:00 p.m. confirmed that the dialysis communication binder was incomplete.

28 Pa Code 211.5 (f)(ii) Medical records.

28Pa. Code 211.12 (d)(3) Nursing services.







 Plan of Correction - To be completed: 07/14/2026

Resident R1 had no adverse effect.
DON/designee completed an initial audit for all residents receiving dialysis to ensure dialysis communication records are complete with consistent documentation.
NPE/designee will re-educate licensed nurses to ensure residents receiving dialysis communication records are complete with consistent documentation.
DON/designee will conduct weekly audits x
4, then monthly X2 of residents receiving dialysis to ensure communication records are complete with consistent documentation.
DON/designee will review results of audits with the QAPI committee monthly X 3. Audits will continue if identified as necessary.


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