Deficiency Records for Hilltop Healthcare Rehabilitation and Skilled Nurs
Updated as of April 01, 2024
A list of the most recent deficiencies for Hilltop Healthcare Rehabilitation and Skilled Nurs. 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? |
|---|---|---|---|---|
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-02-20 | 2024-04-03 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2024-02-20 | 2024-04-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-20 | 2024-04-03 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-02-20 | 2024-04-03 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-02-20 | 2024-04-03 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-02-20 | 2024-04-03 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-02-16 | 2024-03-18 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2024-02-16 | 2024-03-15 | 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 | 2024-02-16 | 2024-03-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-16 | 2024-03-15 | 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 | 2024-02-16 | 2024-03-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-16 | 2024-03-15 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2024-02-16 | 2024-03-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-02-16 | 2024-03-15 | Y |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-02-20 | 2024-03-08 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-02-20 | 2024-03-04 | 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 | 2024-02-20 | 2024-03-04 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-02-20 | 2024-03-04 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-02-20 | 2024-03-04 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2023-11-22 | 2023-12-27 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-06-06 | 2023-08-17 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-06-06 | 2023-08-17 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-06-06 | 2023-08-17 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2023-06-12 | 2023-07-26 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-06-12 | 2023-07-26 | 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 | 2023-06-12 | 2023-07-26 | 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 | 2023-06-12 | 2023-07-26 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-06-12 | 2023-07-26 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-06-12 | 2023-07-26 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-06-12 | 2023-07-24 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-06-12 | 2023-07-24 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2023-06-12 | 2023-07-24 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-06-12 | 2023-07-24 | N |
| 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. | Health | 2023-06-12 | 2023-07-24 | 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 | 2023-06-12 | 2023-07-24 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2023-06-12 | 2023-07-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-12 | 2023-07-24 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-12 | 2023-07-24 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-06-12 | 2023-07-24 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-06-12 | 2023-07-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-06-12 | 2023-07-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-06-12 | 2023-07-24 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-06-12 | 2023-07-24 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-12 | 2023-07-24 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-12 | 2023-07-24 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-12 | 2023-07-24 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2023-06-12 | 2023-07-24 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-06-12 | 2023-07-21 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-06-06 | 2023-07-21 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-06-06 | 2023-07-21 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-06-06 | 2023-07-21 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-06-06 | 2023-07-21 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-06-06 | 2023-07-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-06-06 | 2023-07-21 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-06-06 | 2023-07-21 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-06-06 | 2023-07-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-06-06 | 2023-07-21 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2023-06-12 | 2023-07-16 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-03-01 | 2022-12-21 | 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 | 2022-03-01 | 2022-12-21 | N |
| Install properly constructed windows in hallway walls or doors. | Fire Safety | 2022-03-01 | 2022-12-21 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-11-17 | 2022-11-19 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-19 | 2022-08-25 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-04 | 2022-08-19 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-03 | 2022-04-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-03-03 | 2022-04-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-03 | 2022-04-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-03 | 2022-04-04 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-03-03 | 2022-04-04 | 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 | 2022-03-03 | 2022-04-01 | 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 | 2022-03-03 | 2022-04-01 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-03-03 | 2022-04-01 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2022-03-01 | 2022-04-01 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-03-03 | 2022-03-31 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-03-01 | 2022-03-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-03-01 | 2022-03-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-03-01 | 2022-03-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-03-01 | 2022-03-22 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-03-01 | 2022-03-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-03-01 | 2022-03-21 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-03-01 | 2022-03-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-03-01 | 2022-03-21 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-03-01 | 2022-03-21 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-03 | 2021-11-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-22 | 2021-10-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-09-10 | 2021-10-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-10 | 2021-10-08 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-08-03 | 2021-09-01 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-06-24 | 2021-07-28 | Y |
