The resident told inspectors on January 7 that she had been discharged from the hospital two weeks earlier with a new pancreatic medication but hadn't received it since returning to the facility. When inspectors checked her medication cart that morning, they found a sealed bottle of Creon labeled for the resident with a pharmacy fill date of January 6.
The licensed nurse said the resident would start the medication the following day.
But the resident's medication administration records told a different story. They showed she had received doses on December 25, 28, 29, 30, and 31, plus January 3 and 4. The Director of Nursing later confirmed the resident received her first dose on January 7 and verified she did not receive any of the doses documented in the records.
When inspectors had a nurse count the remaining capsules on January 9, they found 88 capsules in a bottle that originally contained 100. According to the medication records, 16 capsules should have been administered since January 7. That would have left 84 capsules.
The resident needed Creon with meals to help digest food properly. Her physician had ordered two capsules by mouth with meals for pancreatic insufficiency.
Kitchen staff at the 88-bed facility also ignored basic dietary requirements during the January 8 inspection. Inspectors watched the lunch service and found cooks serving white rice instead of the brown rice listed on the posted menu. When questioned, the cook admitted not looking closely at the menu.
"It does indeed say brown rice," the cook told inspectors. "I did not look at it closely and made white rice instead."
The registered dietitian wasn't notified about the substitution. She later explained that brown rice contains more fiber and nutrients than white rice, and she should have been informed when the menu wasn't followed to ensure residents received proper nutrition.
Two residents with malnutrition didn't receive the fortified meals they were prescribed. Resident 32, who had moderate protein-calorie malnutrition, was supposed to get melted butter added to vegetables and rice for extra calories. The cook forgot to add it and only corrected the plate after inspectors pointed out the omission.
Resident 86, who had a fractured leg, also missed the butter fortification on his carrots. His meal was already covered and heading to the food cart when inspectors noticed the error.
The Food Nutrition Service Manager said fortified foods were required for residents experiencing weight loss, and failing to provide the additives meant not meeting residents' nutritional needs. The registered dietitian explained that fortified additives provide additional calories for residents with weight loss, and missing them could contribute to further decline.
Five residents received foods they specifically disliked or couldn't eat, despite having their preferences clearly marked on meal tickets.
Resident 1 received fish even though her meal ticket listed fish as a dislike. She told inspectors the next day that if fish was served to her, she wouldn't eat it. Someone had told her she was losing weight, and she attributed it partly to not liking some of the food.
A vegetarian resident got a meat patty instead of a veggie patty. The cook said he ran out of vegetarian patties but offered no explanation for serving meat instead. The resident, who had been vegetarian since age 4, said she would immediately recognize meat and simply wouldn't eat it.
Resident 75 received tomato soup despite her meal ticket showing she liked soup but disliked tomato soup specifically. "I love soup, but I hate tomato soup specifically," she told inspectors. "I would not get upset if it was given to me, I just would not eat it."
Another resident who disliked cranberries got a cranberry dessert bar. A fifth resident who was supposed to receive double portions of meat, fish, or eggs got only a small piece of fish.
The facility's food preferences policy required staff to honor resident preferences and obtain them within seven days of admission. Kitchen staff were expected to review meal cards and compare them to plated meals during service.
Medical record problems extended beyond the falsified medication documentation. Nurses incorrectly documented a dialysis patient's access site on five separate communication forms over five weeks.
Resident 71 had a Perma-cath, a central line inserted into a main vein in her upper right chest. But nurses documented that she had a dialysis graft, an internal surgical connection between an artery and vein, on forms dated December 3, 19, 23, 27, and January 2.
The resident showed inspectors her Perma-cath after returning from dialysis treatment. She went three times a week on Tuesdays, Thursdays, and Saturdays.
The Director of Staff Development explained that grafts can only be assessed by listening for a bruit and feeling for a thrill since they're internal. Perma-caths require visual assessment for bleeding and infection signs.
Two nurses admitted their errors when confronted. Licensed Nurse 7 reviewed her December 19 form and acknowledged documenting a graft with bruit and thrill when the resident actually had a Perma-cath. "I know the difference between the two and I made an error," she said.
Licensed Nurse 8 made the same mistake on December 23, documenting bruit and thrill for a Perma-cath. Both nurses agreed accurate documentation was important so everyone reviewing the record would understand the resident's condition.
The Director of Nursing said post-dialysis assessments were crucial for identifying early signs of bleeding, infection, or complications. She had recently provided dialysis training during annual skills assessments but acknowledged the inaccurate documentation could confuse readers.
The Director of Staff Development had been at the facility four months but hadn't provided any in-services or education to licensed nurses about dialysis access sites.
The inspection found violations in medication administration, dietary services, food preferences, and medical record accuracy. All carried minimal harm ratings but affected multiple residents across basic care functions.
Resident 30 continues to need her pancreatic medication with every meal. The sealed bottle that should have been empty sits as evidence of two weeks when her digestive system worked without the help it required.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Hillcrest Heights Healthcare Center from 2025-01-09 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Hillcrest Heights Healthcare Center
- Browse all CA nursing home inspections