Deficiency Records for Hilltop Lodge Health and Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Hilltop Lodge Health and Rehabilitation Center. 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? |
|---|---|---|---|---|
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-11-20 | 2023-11-24 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-05-01 | 2023-05-31 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-05-01 | 2023-05-31 | Y |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-04-18 | 2023-04-21 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2023-02-16 | 2023-02-16 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-11-21 | 2022-11-28 | Y |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2022-08-02 | 2022-08-30 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-08-02 | 2022-08-30 | N |
| Use approved construction type or materials. | Fire Safety | 2022-08-02 | 2022-08-30 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-08-02 | 2022-08-30 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-08-02 | 2022-08-30 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-08-02 | 2022-08-30 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-08-02 | 2022-08-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-08-02 | 2022-08-30 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-06-16 | 2022-07-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-06-16 | 2022-07-20 | N |
| 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. | Health | 2022-06-16 | 2022-07-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-16 | 2022-07-20 | 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 | 2022-06-16 | 2022-07-20 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2022-06-16 | 2022-07-20 | 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 | 2022-06-16 | 2022-07-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-16 | 2022-07-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-16 | 2022-07-20 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-06-16 | 2022-07-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-14 | 2021-09-09 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-07-07 | 2021-08-18 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-12-09 | 2021-01-15 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2020-12-09 | 2021-01-15 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2020-12-09 | 2021-01-15 | 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 | 2020-12-09 | 2021-01-15 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2020-12-09 | 2021-01-15 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2020-12-09 | 2021-01-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-12-09 | 2021-01-15 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-12-09 | 2021-01-15 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-12-09 | 2021-01-15 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2020-12-09 | 2021-01-15 | 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 | 2020-12-09 | 2021-01-15 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2020-12-09 | 2021-01-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-12-09 | 2021-01-15 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2020-12-09 | 2021-01-04 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2020-12-09 | 2021-01-04 | N |
| Establish emergency prep training and testing. | Fire Safety | 2020-12-09 | 2021-01-04 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-12-09 | 2021-01-04 | N |
| Implement emergency and standby power systems. | Fire Safety | 2020-12-09 | 2021-01-04 | N |
| Use approved construction type or materials. | Fire Safety | 2020-12-09 | 2021-01-04 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-12-09 | 2021-01-04 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2020-12-09 | 2021-01-04 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-12-09 | 2021-01-04 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-12-09 | 2021-01-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-12-09 | 2021-01-04 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2020-12-09 | 2021-01-04 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2020-12-09 | 2021-01-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-12-09 | 2021-01-04 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2020-12-09 | 2021-01-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-12-09 | 2021-01-04 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2020-12-09 | 2021-01-04 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-12-09 | 2021-01-04 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2020-12-09 | 2021-01-04 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2020-12-09 | 2021-01-04 | N |
| Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. | Health | 2019-05-06 | 2019-06-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-05-06 | 2019-06-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-05-06 | 2019-05-09 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2019-05-06 | 2019-05-09 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2019-02-14 | 2019-03-22 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2019-02-14 | 2019-03-22 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-02-14 | 2019-03-22 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2019-02-14 | 2019-03-22 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2019-02-14 | 2019-03-22 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2019-02-14 | 2019-03-22 | N |
| Develop a communication plan. | Fire Safety | 2019-02-14 | 2019-03-22 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2019-02-14 | 2019-03-22 | N |
| Establish emergency prep training and testing. | Fire Safety | 2019-02-14 | 2019-03-22 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-02-14 | 2019-03-22 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-02-14 | 2019-03-22 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2019-02-14 | 2019-03-22 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-02-14 | 2019-03-22 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-02-14 | 2019-03-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-02-14 | 2019-03-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-02-14 | 2019-03-22 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-02-14 | 2019-03-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-02-14 | 2019-03-22 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-02-14 | 2019-03-22 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2019-02-14 | 2019-03-22 | N |
