HILLCREST REHABILITATION & HEALTHCARE CENTER Inspection Report, Violations & Safety Grade (LOWER BURRELL, Pennsylvania)

100 LITTLE DRIVE, LOWER BURRELL, Pennsylvania 15068

Phone: 7243391071

CMS Overall:1/5

Overview & Bed Count

Certified Beds

103

Avg Residents/Day

63.5

Ownership

For profit - Limited Liability company

Provider Type

Medicare and Medicaid

County

Westmoreland

Sprinkler Systems

Yes

Special Focus

None

Abuse Icon

CMS Star Ratings

Overall1/5

Health1/5

Staffing1/5

Quality4/5

Nurse Staffing Check

Metric	This Facility	Pennsylvania Avg	Difference
RN Hours per Resident per Day	0.99	0.78	+0.22
Total Nurse Hours per Resident per Day	3.77	3.90	-0.12
CMS Staffing Rating	1/5	3.1/5	-
Nursing Staff Turnover	56.4%	44.6%	-

Health Citation History

81 health citations on record

Date	Category	Description	Severity
2026-04-17	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	F – Moderate Harm Potential
2026-04-17	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.	E – Moderate Harm Potential
2026-04-17	Quality of Life and Care Deficiencies	Provide enough food/fluids to maintain a resident's health.	E – Moderate Harm Potential
2026-04-17	Quality of Life and Care Deficiencies	Provide safe and appropriate respiratory care for a resident when needed.	E – Moderate Harm Potential
2026-04-17	Pharmacy Service Deficiencies	Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.	E – Moderate Harm Potential
2026-04-17	Administration Deficiencies	Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.	E – Moderate Harm Potential
2026-04-17	Infection Control Deficiencies	Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.	E – Moderate Harm Potential
2026-04-17	Administration Deficiencies	Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.	E – Moderate Harm Potential
2026-04-17	Resident Rights Deficiencies	Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.	E – Moderate Harm Potential
2026-04-17	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.	E – Moderate Harm Potential
2026-04-17	Administration Deficiencies	Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.	E – Moderate Harm Potential
2026-04-17	Infection Control Deficiencies	Include as part of its infection prevention and control program, mandatory training that includes written standards, policies, and procedures for the program.	E – Moderate Harm Potential
2026-04-17	Administration Deficiencies	Provide training in compliance and ethics.	E – Moderate Harm Potential
2026-04-17	Nursing and Physician Services Deficiencies	Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.	E – Moderate Harm Potential
2026-04-17	Administration Deficiencies	Provide behavior health training consistent with the requirements and as determined by a facility assessment.	E – Moderate Harm Potential
2026-04-17	Resident Rights Deficiencies	Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.	D – Moderate Harm Potential
2026-04-17	Resident Assessment and Care Planning Deficiencies	Ensure each resident receives an accurate assessment.	D – Moderate Harm Potential
2026-04-17	Resident Assessment and Care Planning Deficiencies	Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.	D – Moderate Harm Potential
2026-04-17	Quality of Life and Care Deficiencies	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	D – Moderate Harm Potential
2026-04-17	Quality of Life and Care Deficiencies	Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.	D – Moderate Harm Potential
2026-04-17	Pharmacy Service Deficiencies	Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.	D – Moderate Harm Potential
2026-04-17	Infection Control Deficiencies	Develop and implement policies and procedures for flu and pneumonia vaccinations.	D – Moderate Harm Potential
2026-04-17	Environmental Deficiencies	Keep all essential equipment working safely.	D – Moderate Harm Potential
2026-02-11	Quality of Life and Care Deficiencies	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	D – Moderate Harm Potential
2025-12-17	Pharmacy Service Deficiencies	Ensure that residents are free from significant medication errors.	D – Moderate Harm Potential
2025-12-02	Quality of Life and Care Deficiencies	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	D – Moderate Harm Potential
2025-07-31	Quality of Life and Care Deficiencies	Provide care and assistance to perform activities of daily living for any resident who is unable.	E – Moderate Harm Potential
2025-06-05	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	G – Actual Harm
2025-06-05	Quality of Life and Care Deficiencies	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.	G – Actual Harm
2025-05-07	Resident Rights Deficiencies	Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.	D – Moderate Harm Potential
2025-05-07	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Develop and implement policies and procedures to prevent abuse, neglect, and theft.	D – Moderate Harm Potential
2025-05-07	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Respond appropriately to all alleged violations.	D – Moderate Harm Potential
2025-03-07	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	F – Moderate Harm Potential
2025-03-07	Resident Rights Deficiencies	Allow resident to participate in the development and implementation of his or her person-centered plan of care.	E – Moderate Harm Potential
2025-03-07	Resident Rights Deficiencies	Honor the resident's right to organize and participate in resident/family groups in the facility.	E – Moderate Harm Potential
2025-03-07	Quality of Life and Care Deficiencies	Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.	E – Moderate Harm Potential
2025-03-07	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.	D – Moderate Harm Potential
2025-03-07	Resident Assessment and Care Planning Deficiencies	Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted	D – Moderate Harm Potential
2025-03-07	Resident Assessment and Care Planning Deficiencies	Ensure services provided by the nursing facility meet professional standards of quality.	D – Moderate Harm Potential
2025-03-07	Quality of Life and Care Deficiencies	Provide care and assistance to perform activities of daily living for any resident who is unable.	D – Moderate Harm Potential
2025-03-07	Quality of Life and Care Deficiencies	Provide appropriate pressure ulcer care and prevent new ulcers from developing.	D – Moderate Harm Potential
2025-03-07	Quality of Life and Care Deficiencies	Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.	D – Moderate Harm Potential
2025-03-07	Quality of Life and Care Deficiencies	Provide enough food/fluids to maintain a resident's health.	D – Moderate Harm Potential
2025-03-07	Quality of Life and Care Deficiencies	Provide safe and appropriate respiratory care for a resident when needed.	D – Moderate Harm Potential
2025-03-07	Quality of Life and Care Deficiencies	Provide safe, appropriate dialysis care/services for a resident who requires such services.	D – Moderate Harm Potential
2025-03-07	Pharmacy Service Deficiencies	Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.	D – Moderate Harm Potential
2025-03-07	Pharmacy Service Deficiencies	Ensure that residents are free from significant medication errors.	D – Moderate Harm Potential
2025-03-07	Pharmacy Service Deficiencies	Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.	D – Moderate Harm Potential
2025-03-07	Quality of Life and Care Deficiencies	Provide or get specialized rehabilitative services as required for a resident.	D – Moderate Harm Potential
2025-03-07	Administration Deficiencies	Have the Quality Assessment and Assurance group have the required members and meet at least quarterly	D – Moderate Harm Potential

Showing 50 of 81 citations.

Fire Safety Citation History

3 fire safety citations on record

Date	Category	Description	Severity
2025-03-07	Smoke Deficiencies	Install corridor and hallway doors that block smoke.	E – Moderate Harm Potential
2024-05-17	Smoke Deficiencies	Inspect, test, and maintain automatic sprinkler systems.	E – Moderate Harm Potential
2024-05-17	Gas, Vacuum, and Electrical Systems Deficiencies	Ensure proper usage of power strips and extension cords.	E – Moderate Harm Potential

Total Penalties & Fines

Total Fine Amount (CMS)

Number of Fines

Total Penalties

No penalty records found.

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