Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hillcrest Care Center Inc during CMS and state inspections, most recent first.
A bookkeeper misappropriated over $20,000 from resident trust accounts and cash by failing to follow required documentation procedures, including obtaining witness signatures and providing detailed reasons for withdrawals. Many affected residents had cognitive impairments and reported not receiving or requesting cash, despite their signatures appearing on disbursement logs. The bookkeeper also failed to deposit funds provided by resident representatives, resulting in missing or unaccounted-for resident funds.
The facility failed to maintain a safe and clean environment, with observations of unsanitary conditions in the smoking area, courtyard, and various indoor locations. Issues included dead insects, cigarette butts, exposed sheetrock, and grime buildup. Staff interviews revealed unclear responsibilities and inconsistent use of maintenance logs, contributing to the neglect of these areas.
The facility failed to provide written notification to residents and their representatives regarding hospital transfers. Four residents were transferred multiple times without documented notifications. Interviews revealed that the required transfer/discharge forms were not completed or maintained, and the Social Service Designee did not follow up on these forms, indicating a systemic issue in the facility's process.
The facility failed to notify residents and/or their representatives in writing of the bed hold policy during hospital transfers. This deficiency was identified for four residents who were transferred multiple times without documented notification. Interviews with staff revealed that the bed hold policy forms were not being completed or maintained, with the ADON, Administrator, and SSD acknowledging lapses in the process.
The facility failed to document and manage pressure ulcers for two residents, leading to deficiencies in care. One resident, with severe cognitive impairment and limited mobility, had an open area on the left buttock without proper documentation or treatment orders. Another resident, also with severe cognitive impairment, had a nickel-sized eschar on the right heel, but heel protectors were not used consistently. Staff interviews revealed a lack of awareness and adherence to care plans, contributing to inadequate care.
The facility failed to document communication between the facility and the dialysis center for residents requiring dialysis. Despite policies requiring a Dialysis Communication Record for each visit, the facility missed numerous opportunities to complete these forms for residents with end-stage renal disease and chronic kidney disease. Interviews revealed inconsistencies in sending communication logs and checking for bruit and thrill, indicating systemic issues in maintaining proper documentation.
The facility failed to provide the required twelve hours of in-service education and annual Dementia Care competencies for two CNAs. CNA C and CNA D did not meet the training requirements, as confirmed by the DON and Administrator.
A resident with multiple health conditions was left unsupervised outside for several hours after falling over a crack in the sidewalk. Despite staff noticing the resident's absence during the night, no search was initiated until the following morning. The resident was found with abrasions and required hospital evaluation.
Misappropriation of Resident Funds by Bookkeeper
Penalty
Summary
The facility failed to protect the personal property and funds of 26 out of 27 sampled residents when a bookkeeper misappropriated a total of $20,110 from resident trust accounts and cash. The misappropriation occurred over several months, during which the bookkeeper used resident funds for personal use. Facility policy required that cash withdrawals from resident trust accounts be documented with detailed disbursement logs, including signatures from the resident, the bookkeeper, and a witness. However, the bookkeeper repeatedly failed to obtain the required witness signatures and labeled withdrawals as 'personal spending' without sufficient detail, in violation of facility policy. Multiple residents with moderate to severe cognitive impairment, including those with diagnoses such as dementia, schizophrenia, and intellectual disabilities, were affected. Interviews with these residents revealed that they did not request or receive cash withdrawals, despite their signatures appearing on disbursement logs. Several residents stated that the bookkeeper had them sign forms without explanation and that they did not receive any money. Staff interviews confirmed that these residents were not observed requesting or carrying cash, and that the bookkeeper was responsible for handling resident trust accounts and cash disbursements. Further review of facility records showed that the bookkeeper accepted cash deposits from resident representatives, issued receipts, but failed to deposit the funds into the appropriate accounts. In several cases, there were no records of deposits or account creation for residents who had provided funds, and receipts were not matched by corresponding entries in the trust accounts or petty cash logs. The bookkeeper had received training on proper procedures but did not follow them, resulting in the wrongful use of resident property and funds.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment, as evidenced by multiple observations of unsanitary and unsafe conditions. The designated smoking area was found to have dead insects, bird droppings, cigarette ashes, and scattered cigarette butts, along with a discarded N95 mask and a broom left against a column. Similar issues were noted in the courtyard, where cigarette butts were scattered on the ground. These conditions were observed over several days, indicating a lack of regular maintenance and cleaning. Inside the facility, the 500 Hall showed significant disrepair, including peeled wallpaper, missing outlet covers, exposed sheetrock, and a large hole in the wall. The dining room had dark scuff marks on the walls and missing trim, while the kitchen's dish return door had a large hole with missing sheetrock and trim. The 300 hallway had a buildup of grime on the floor, and the laundry room was cluttered with clothing, lint, grime, and stagnant water, along with missing drywall and peeled paint from water damage. Interviews with staff revealed a lack of clarity and responsibility regarding maintenance and cleaning duties. Housekeeping staff were unsure who was responsible for cleaning the smoking area, and the maintenance supervisor expected staff to report issues in a maintenance log, which was not consistently used. The floor technician, who was responsible for cleaning the smoking area and maintaining the grounds, was covering in the laundry department, leading to neglect in other areas. The administrator and maintenance supervisor both expressed expectations for a clean environment, but these were not met in practice.
Failure to Notify Residents of Hospital Transfers
Penalty
Summary
The facility failed to provide timely written notification to residents and their representatives regarding transfers or discharges to a hospital. This deficiency was identified for four residents out of a sample of four, with a facility census of 80. The medical records of these residents showed multiple instances of hospital transfers without documented written notifications. For example, one resident was transferred to the hospital on two occasions, and another resident was transferred three times, yet there was no documentation of written notification for any of these transfers. Interviews with facility staff revealed a lack of adherence to the transfer/discharge notification process. The Assistant Director of Nursing indicated that nursing staff should complete a transfer/discharge form before a resident is transferred to the hospital, and a copy should be given to the Social Service Designee (SSD) for documentation. However, the Administrator acknowledged that these forms were not completed or maintained as required. The SSD admitted to not following up with the transfer/discharge forms for residents sent to the hospital, indicating a systemic issue in the facility's process for handling transfers and discharges.
Failure to Notify Residents of Bed Hold Policy
Penalty
Summary
The facility failed to notify residents and/or their representatives in writing of the bed hold policy at the time of transfer to the hospital for four residents. This deficiency was identified through interviews and record reviews, which revealed that there was no documentation of the bed hold policy being communicated in writing for Residents #7, #20, #46, and #279. Each of these residents had been transferred to the hospital on multiple occasions, yet there was no evidence that the facility provided the required written notification regarding the bed hold policy. Interviews with facility staff, including the Assistant Director of Nursing (ADON), the Administrator, and the Social Service Designee (SSD), confirmed that the bed hold policy forms were not being completed or maintained as required. The ADON indicated that nursing staff should fill out the bed hold policy form before a resident is transferred to the hospital, and a copy should be given to the SSD for documentation. However, the Administrator acknowledged that these forms were not being completed or kept, and the SSD admitted to not following up on the bed hold policy forms for residents transferred to the hospital.
Deficient Pressure Ulcer Care and Documentation
Penalty
Summary
The facility failed to adequately document and manage pressure ulcers for two residents, leading to deficiencies in care. Resident #38, who was admitted with severe cognitive impairment and limited mobility, was at risk for pressure ulcers. Despite being identified as at moderate risk for skin breakdown, the facility did not have any documented orders for skin care related to the resident's left buttock. A skin assessment on 10/23/24 revealed an open area on the left buttock, but there was no documentation of the type, stage, measurements, or characteristics of the injury. Interviews with staff indicated a lack of awareness and documentation regarding the resident's skin condition, with the Director of Nursing only placing an order for skin prep after the issue was identified. Resident #46, also with severe cognitive impairment and dependent on staff for mobility, was at risk for pressure ulcers. The resident's medical record showed an order for skin prep to the heels, but there was no documentation of any skin conditions with specific details. Observations revealed a nickel-sized eschar on the right heel, yet the resident's heels were not floated as required, and heel protectors were not used consistently. Interviews with staff highlighted a lack of adherence to care plans and proper documentation, with the Assistant Director of Nursing acknowledging the need for weekly skin assessments with detailed measurements and staging. The facility's failure to document and manage pressure ulcers appropriately for these residents indicates a deficiency in following established protocols for pressure ulcer prevention and care. The lack of documentation and awareness among staff members contributed to inadequate care, as evidenced by the absence of detailed assessments and the inconsistent use of protective measures for residents at risk of skin breakdown.
Failure to Document Dialysis Communication
Penalty
Summary
The facility failed to provide adequate documentation of communication between the facility and the dialysis center for three residents requiring dialysis services. The facility's policy mandates that a Dialysis Communication Record be sent with residents on each dialysis visit, detailing care concerns, medications, and contact information. However, the review of the Dialysis Communication logs from July to October 2024 revealed numerous missed opportunities for completing these forms for Residents #6, #11, and #32. Resident #6, diagnosed with end-stage renal disease and dependent on renal dialysis, had orders for dialysis thrice weekly and required daily checks of the shunt for bruit and thrill. Despite these requirements, the facility failed to complete the Dialysis Communication forms consistently, missing all opportunities from July to September 2024 and most in October 2024. Similarly, Resident #11, with chronic kidney disease and other health issues, also had orders for dialysis thrice weekly and required checks of the AV fistula every shift. The facility again missed all opportunities to complete the communication forms from July to September 2024 and most in October 2024. Resident #32, with severe kidney damage and ESRD, also required dialysis thrice weekly and monitoring of the shunt site. The facility failed to complete the Dialysis Communication forms for all opportunities from July to September 2024 and most in October 2024. Interviews with staff and residents revealed inconsistencies in sending communication logs and checking for bruit and thrill, indicating a systemic issue in maintaining proper communication and documentation for residents undergoing dialysis.
Deficiency in Nurse Aide In-Service Education and Dementia Care Training
Penalty
Summary
The facility failed to conduct the required twelve hours of nurse aide in-service education per year and did not provide the necessary annual competencies in Dementia Care for two sampled nurse aides. The facility's assessment, revised in September 2024, outlined the requirements for in-service training, which included dementia management training and resident abuse prevention training. However, the facility did not have a policy in place for nurse aide in-service education, which contributed to the deficiency. Review of the in-service records from June 2023 to June 2024 showed that CNA C, hired on June 23, 2023, attended only nine hours and 30 minutes of in-services and did not complete the annual competency in Dementia Care. Similarly, CNA D, hired on July 11, 2023, attended only seven hours of in-services and also did not complete the required Dementia Care competency. Interviews with the Director of Nursing and the Administrator confirmed that nurse aides should receive 12 hours of education training annually, including Dementia Care, which was not met in these cases.
Resident Left Unsupervised Outside for Extended Period
Penalty
Summary
The facility failed to provide adequate supervision and implement its policy for missing residents, resulting in a resident being left outside for an extended period. On the night of 07/31/24, a resident with a history of amyotrophic lateral sclerosis, transient ischemic attack, depression, chronic kidney disease, high blood pressure, and diabetes mellitus type 2, went outside to pray and fell over a crack in the sidewalk. The resident was not accounted for until the following morning, despite staff noticing the resident's call light on and the room empty at 3:00 A.M. The staff did not initiate a search or follow the facility's Elopement-Missing Resident policy when the resident was first noticed missing. The resident was last seen by the Director of Nursing at approximately 11:30 P.M. on 07/31/24, and was not seen again until found outside at 8:15 A.M. on 08/01/24. During this time, the resident sustained multiple abrasions and was exposed to the elements for several hours. Interviews with staff revealed a lack of communication and action regarding the resident's absence. The Certified Medication Technician and Licensed Practical Nurse did not take immediate action to locate the resident, and the Director of Nursing was not informed of the resident's absence until much later. The facility's failure to account for the resident and initiate a timely search led to the resident being found with injuries and requiring hospital evaluation.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 46 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near De Soto
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stonebridge Desoto | 4.2 mi | — | 0 | 0 |
| Baisch Nursing Center | 6.5 mi | — | 0 | 0 |
| Superior Manor Of Festus, Llc | 8.8 mi | — | 0 | 0 |
| Festus Manor | 9.4 mi | — | 0 | 0 |
| Crystal Oaks | 9.6 mi | — | 4 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Hillcrest Care Center Inc.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.