A list of the most recent deficiencies for Hilltop Skilled Nsg and Rehab. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-02-26 | 2024-02-27 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-01-27 | 2024-02-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-01 | 2023-12-21 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-10-28 | 2023-12-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-10-28 | 2023-12-20 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-11-01 | 2023-12-20 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-11-01 | 2023-12-20 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-11-01 | 2023-12-20 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-11-01 | 2023-12-20 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-11-01 | 2023-12-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-11-01 | 2023-12-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-11-01 | 2023-12-20 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-11-01 | 2023-12-20 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-11-01 | 2023-12-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-11-01 | 2023-12-20 | N |
| 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. | Health | 2023-11-01 | 2023-12-20 | N |
| Post nurse staffing information every day. | Health | 2023-11-01 | 2023-12-20 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-11-01 | 2023-12-20 | N |
| 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. | Health | 2023-11-01 | 2023-12-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-01 | 2023-12-20 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-11-01 | 2023-12-20 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-11-01 | 2023-12-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-01 | 2023-12-20 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-11-01 | 2023-12-20 | N |
| 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. | Health | 2023-11-01 | 2023-12-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-12-05 | 2023-12-06 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-11-07 | 2023-11-30 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2023-11-07 | 2023-11-24 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-11-07 | 2023-11-24 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-11-07 | 2023-11-24 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2023-11-07 | 2023-11-24 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-11-07 | 2023-11-24 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-11-07 | 2023-11-24 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-11-07 | 2023-11-24 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-11-07 | 2023-11-24 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-11-07 | 2023-11-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-11-07 | 2023-11-24 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-09-29 | 2023-10-02 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-09-29 | 2023-09-30 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-09-29 | 2023-09-30 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-29 | 2023-09-30 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-06 | 2023-09-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-28 | 2023-08-31 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-06-07 | 2023-06-21 | Y |
| Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. | Health | 2023-06-07 | 2023-06-21 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-06-07 | 2023-06-21 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-06-07 | 2023-06-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-16 | 2023-03-08 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-12 | 2023-02-03 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-12-27 | 2023-01-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-27 | 2023-01-24 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2022-12-27 | 2023-01-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-12-27 | 2023-01-24 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-12-27 | 2023-01-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-12-27 | 2023-01-24 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2022-12-12 | 2023-01-19 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-12-12 | 2023-01-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-12 | 2023-01-19 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-12-12 | 2023-01-19 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-12-12 | 2023-01-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-12-12 | 2023-01-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-12-12 | 2023-01-19 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-12-12 | 2023-01-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-30 | 2022-10-03 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-30 | 2022-10-03 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-09-30 | 2022-10-03 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-03-09 | 2022-03-31 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-03-09 | 2022-03-31 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-01-27 | 2022-02-17 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-01-27 | 2022-02-17 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-01-27 | 2022-02-17 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-01-27 | 2022-02-17 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-01-27 | 2022-02-17 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-10-26 | 2021-11-12 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-11-08 | 2021-11-11 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-10-01 | 2021-10-07 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-10-01 | 2021-10-07 | N |
| Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. | Fire Safety | 2021-10-01 | 2021-10-07 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-10-01 | 2021-10-07 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-10-01 | 2021-10-07 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2021-10-01 | 2021-10-07 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-09-10 | 2021-10-04 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-09-10 | 2021-10-04 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2021-09-10 | 2021-10-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-10 | 2021-10-04 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-09-10 | 2021-10-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-09-10 | 2021-10-04 | N |
| 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. | Health | 2021-09-10 | 2021-10-04 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2021-09-10 | 2021-10-04 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-09-10 | 2021-10-04 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-09-10 | 2021-10-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-09-10 | 2021-10-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-10 | 2021-10-04 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2021-09-10 | 2021-10-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-10 | 2021-10-04 | Y |
