Hillcrest Health Care Center
Hillcrest Health Care Center in Hawarden, IA — inspection on March 26, 2026.
Found 6 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Observation of her urinal was noted to have brown areas on the outside and noted to have a urine scale in the bottom of the urinal.
She explained the brown areas on the outside of the urinal is feces that has been there awhile.
She explained the facility has not changed the urinal for approximately 3 months and does not clean it weekly.
Observation of the urinal top also showed a bend in the top of the urinal and she stated that it does not work as well when it has the bend.
The facility did not provide a policy on urinal care.
Interview on 3/25/2026 at 3:23 p.m., with the Director of Nursing (DON) revealed she doesn't know what the facility staff does with Resident #17's urinal.
The DON revealed the male urinals are changed monthly so hers should be as well.
She is unsure if the facility has any new urinals for her in the facility at this time but they should.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
165245 03/26/2026
Hillcrest Health Care Center 2121 Avenue L Hawarden, IA 51023
Review of Resident #10's EHR titled, Census documented Resident #10 was transferred to the hospital 1/7/26 and returned 1/22/26.Review of Resident #10's EHR titled, Progress Note documented an entry at 5:40 AM on 1/7/26 by Staff E, Licensed Practical Nurse (LPN) on-call provider gave orders to send Resident #10 to the ED via ambulance for evaluation and supply oxygen, updated resident on orders as resident is own POA.Review of Resident #10's EHR titled, Progress Note documented an entry at 11:31 AM on 1/7/26 by Staff D, LPN had spoken with ED nurse with report that Resident #10 was transferred to another hospital in Sioux Falls because of urosepsis and kidney failure.
Staff D documented she called and notified Resident #10's Daughter.Review of Resident #10's EHR titled, Profile documented Daughter as emergency contact #1, POA, care conference person. On 3/17/26 at 10:56 AM Resident #10 Daughter/POA stated when Resident #10 went to the ED on 1/7/26 she was not notified till he went to the second hospital. Resident #10's Daughter/POA explained Resident #10 was life flighted to second hospital and she was not notified until after Resident #10 was in second hospital. Resident #10's Daughter/POA stated she was called by the nursing home about 30 minutes before the second hospital notified her. Resident #10's Daughter/POA stated she spoke to Staff D, Licensed Practical Nurse. Resident #10's Daughter/POA stated she told Staff D she was not notified her father was sent to the hospital and Staff D apologized. On 3/24/26 at 1:35 PM Staff D, LPN stated she called Resident #10's daughter / POA and notified her that Resident #10 was transferred to the ED.
Staff D stated when she arrived the previous nurse Staff E, LPN had not notified the Resident #10's Daughter and Resident #10's daughter was upset.
Staff D stated if the resident was their own POA Staff D would ask to notify the emergency contact.
Staff D explained if the ambulance was called it would be an emergency and the emergency contact should be notified. On 3/25/26 at 6:10 PM Staff E, LPN stated she was familiar with Resident #10.
Staff E explained Resident #10 was his own POA.
Staff E stated if Resident #10 was not his own POA; she would notify the emergency contact.
Staff E explained she did not notify Resident #10's POA when transferred to the hospital on 1/7/26.
Staff E acknowledged she sent Resident #10 out right at 6:00 AM.
Staff E said she texted Staff D to let Resident #10's daughter know Resident #10 was transferred.
Staff E acknowledged that she should have let the daughter know but she did not at that time. On 3/18/26 at 10:54 AM the Director of Nursing (DON) stated Resident #10 was transferred to the hospital via emergency ambulance on 1/7/26.
The DON stated Resident #10 was his own POA at the time but Resident #10's daughter was emergency contact #1 and should have been notified of the transfer to the ED and was not.Review of policy with review date of 7/24 titled, Change of Condition Reporting documented a licensed nurse will inform family/responsible party of change of condition and document notification.
All attempts to reach the physician and responsible party will be documented in the nursing progress notes.
Documentation will include time and response.
165245 03/26/2026
Hillcrest Health Care Center 2121 Avenue L Hawarden, IA 51023
Review of a facility provided policy revised on 05/07 titled, Homelike Environment documented it was the policy of this facility to provide a homelike environment, and to encourage and provide opportunities for each resident to occupy an area reflecting his/her interests, family, and/or is made personalized by bringing photos or items from home.
- Observation on 03/18/2026 at 11:29 a.m., of Resident # 17's room.
The room was noted to have the bed pulled away from the wall and the floor was noted to have streaks of dried fluid.
The baseboard heat was noted to have brown debris scattered along the area next to the bed.
The baseboard heat was also noted to have a white object in the baseboard.
The wall above the baseboard heat noted to have several areas of brown debris on the wall. Resident #17 confirmed the areas had been there for a while and unsure what the debris is.
Review of the facility provided policy titled Homelike Environment with a revised date of 5/2007 revealed it is the policy of this facility to provide a homelike environment Interview on 03/25/26 at 2:59 p.m., with the Administrator revealed the rooms should be clean.
165245 03/26/2026
Hillcrest Health Care Center 2121 Avenue L Hawarden, IA 51023
Review of a policy provided by the facility reviewed on 1/22 titled, Abuse: Prevention of and Prohibition Against documented it was the policy of the facility that each resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation.
The Facility will provide oversight and monitoring to ensure that its staff, who are agents of the Facility, deliver care and services in a way that promotes and respects the rights of the residents to be free from abuse, neglect, misappropriation of resident property, and exploitation. To assist the Facility's staff members in recognizing incidents of possible abuse, neglect, misappropriation of resident property, or exploitation, the following definitions are provided: Abuse is willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish.
This includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being.
Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology.
Sexual abuse is non-consensual sexual contact of any type with a resident.
165245 03/26/2026
Hillcrest Health Care Center 2121 Avenue L Hawarden, IA 51023
Administrator. b.
Allegations of abuse, neglect, misappropriation of resident property, or exploitation
the Administrator revealed once she became aware of the situation that evening she immediately
with the DON revealed she did not know about the incident until later in the evening about the touching or being in bed with another resident.
The DON confirmed she had been called around 3:00 p.m., but the staff never told her about the incident.
165245 03/26/2026
Hillcrest Health Care Center 2121 Avenue L Hawarden, IA 51023
Review of facility provided documentation titled Follow Up Question Report dated 1/19/26-3/19/26 revealed the following information:2/7/26- bathing was documented as refused.
Resident received a bath on 2/4/26 and again on 2/11/26.
Resident went 6 days without a bath. 3/11/26- bathing was documented as not applicable.
Resident received a bath on 3/7/26 and again on 3/14/26.
Resident went 6 days without a bath.
Review of Care Plan with a revision date of 2/7/25 revealed resident is totally dependent on staff to provide a bath as necessary. 2.
The MDS assessment dated [DATE] for Resident #50 documented diagnoses of need for assistance with personal care, lack of coordination and hypertension.
The MDS showed the BIMS score of 6 indicating severe cognitive impairment.
Review of facility provided documentation titled Follow Up Question Report dated 1/19/26-3/19/26 revealed the following information:1/24/26- bathing was documented as resident refused.
Resident received a bath on 1/21/26 and again on 1/27/26.
Resident went 6 days with no bath. 2/9/26- bathing was documented as not applicable2/12/26- bathing was documented as not applicable.
Resident had a bath on 2/6/26 and again on 2/13/26.
Resident went 6 days with no bath. 3/2/26- bathing was documented as not applicable.
Resident had a bath on 2/23/26 and again on 3/3/36.
Resident went 7 days with no bath. 3/10/26- bathing was documented as resident refused. 3/11/26- bathing was documented as not applicable3/12/26- bathing was documented as not applicable3/13/26- bathing was documented as not applicable3/14/26- bathing was documented as not applicable3/16/26- bathing was documented as not applicable.
Resident received a bath on 3/6/26 and received a bath again on 3/17/26.
Resident went 11 days with no bath.
Review of the facility provided policy titled Bath, Shower with a revised date of 5/2007 revealed It is the policy of this facility to promote cleanliness, stimulate circulation and assist in relaxation.
Clinical staff members will offer residents a shower at minimum of 2 times per week. If a resident is unable to shower on a specific day, the resident will be offered a shower on the next available day.
Interview on 3/24/2026 at 2:23 p.m., with the Director of Nursing revealed when the resident refused their shower the staff need to continue to offer.
They need to try multiple times and try a different person. If they still do not take it that day the staff need to continue to try the next day until they bathe.