Deficiency Records for The Hilltop at Blue River

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Updated as of March 01, 2024

A list of the most recent deficiencies for The Hilltop at Blue River. 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 pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2023-09-20 2023-09-20 Y
Allow resident to participate in the development and implementation of his or her person-centered plan of care. Health 2023-07-21 2023-08-24 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 2023-07-21 2023-08-24 N
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2023-07-21 2023-08-24 N
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2023-07-21 2023-08-24 N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2023-07-21 2023-08-24 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 2023-07-21 2023-08-24 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2023-07-21 2023-08-24 N
Provide activities to meet all resident's needs. Health 2023-07-21 2023-08-24 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 2023-07-21 2023-08-24 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-07-21 2023-08-24 N
Provide enough food/fluids to maintain a resident's health. Health 2023-07-21 2023-08-24 N
Provide safe, appropriate dialysis care/services for a resident who requires such services. Health 2023-07-21 2023-08-24 N
Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Health 2023-07-21 2023-08-24 N
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Health 2023-07-21 2023-08-24 N
Provide medically-related social services to help each resident achieve the highest possible quality of life. Health 2023-07-21 2023-08-24 N
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Health 2023-07-21 2023-08-24 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 2023-07-21 2023-08-24 N
Ensure medication error rates are not 5 percent or greater. Health 2023-07-21 2023-08-24 N
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Health 2023-07-21 2023-08-24 N
Dispose of garbage and refuse properly. Health 2023-07-21 2023-08-24 N
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. Health 2023-07-21 2023-08-24 N
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. Health 2023-07-21 2023-08-24 N
Provide a neutral and fair arbitration process and agree to arbitrator and venue. Health 2023-07-21 2023-08-24 N
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Health 2023-07-21 2023-08-24 N
Provide and implement an infection prevention and control program. Health 2023-07-21 2023-08-24 N
Implement a program that monitors antibiotic use. Health 2023-07-21 2023-08-24 N
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2023-07-21 2023-08-24 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2023-07-21 2023-08-24 Y
Establish an Emergency Preparedness Program (EP). Fire Safety 2023-07-21 2023-08-24 N
Keep aisles, corridors, and exits free of obstruction in case of emergency. Fire Safety 2023-07-21 2023-08-24 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 2023-07-21 2023-08-24 N
Install proper backup exit lighting. Fire Safety 2023-07-21 2023-08-24 N
Install emergency lighting that can last at least 1 1/2 hours. Fire Safety 2023-07-21 2023-08-24 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 2023-07-21 2023-08-24 N
Provide properly protected cooking facilities. Fire Safety 2023-07-21 2023-08-24 N
Construct fire resistant interior walls. Fire Safety 2023-07-21 2023-08-24 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2023-07-21 2023-08-24 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-07-21 2023-08-24 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2023-07-21 2023-08-24 N
Have simulated fire drills held at unexpected times. Fire Safety 2023-07-21 2023-08-24 N
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2023-07-21 2023-08-24 N
Ensure that smoke control systems are tested and documented in accordance with established engineering principles. Fire Safety 2023-07-21 2023-08-24 N
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. Fire Safety 2023-07-21 2023-08-24 N
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Fire Safety 2023-07-21 2023-08-24 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2023-07-21 2023-08-24 N
Meet requirements for the use of electrical equipment. Fire Safety 2023-07-21 2023-08-24 N
Ensure proper usage of power strips and extension cords. Fire Safety 2023-07-21 2023-08-24 N
Have proper medical gas storage and administration areas. Fire Safety 2023-07-21 2023-08-24 N
Install corridor and hallway doors that block smoke. Fire Safety 2023-07-21 2023-08-24 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2023-05-02 2023-06-17 Y
Ensure services provided by the nursing facility meet professional standards of quality. Health 2023-05-02 2023-06-16 Y
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Health 2023-05-02 2023-06-16 Y
To conduct inspection, testing and maintenance of fire doors by qualified individuals. Fire Safety 2023-05-02 2023-06-16 Y
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 2023-03-31 2023-05-25 Y
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Fire Safety 2023-01-31 2023-03-16 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2022-12-29 2022-12-29 Y
Administer the facility in a manner that enables it to use its resources effectively and efficiently. Health 2022-11-28 2022-12-26 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2022-10-17 2022-10-17 Y
Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. Health 2022-09-12 2022-09-12 Y
Inform each resident of his or her visitation rights and ensure that all visitors enjoy equal visitation privileges. Health 2021-10-12 2021-11-15 Y
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 2021-03-16 2021-04-15 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 2021-03-16 2021-04-15 Y
Provide activities to meet all resident's needs. Health 2021-03-16 2021-04-15 Y
Install proper backup exit lighting. Fire Safety 2021-03-16 2021-04-15 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2021-03-16 2021-04-15 N
Have simulated fire drills held at unexpected times. Fire Safety 2021-03-16 2021-04-15 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2019-06-12 2019-07-22 N
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Health 2019-06-12 2019-07-22 N
Ensure residents have reasonable access to and privacy in their use of communication methods. Health 2019-06-12 2019-07-22 N
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2019-06-12 2019-07-22 N
Respond appropriately to all alleged violations. Health 2019-06-12 2019-07-22 N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2019-06-12 2019-07-22 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 2019-06-12 2019-07-22 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 2019-06-12 2019-07-22 N
Ensure services provided by the nursing facility meet professional standards of quality. Health 2019-06-12 2019-07-22 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2019-06-12 2019-07-22 N
Provide activities to meet all resident's needs. Health 2019-06-12 2019-07-22 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2019-06-12 2019-07-22 N
Provide enough food/fluids to maintain a resident's health. Health 2019-06-12 2019-07-22 N
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Health 2019-06-12 2019-07-22 N
Provide safe, appropriate dialysis care/services for a resident who requires such services. Health 2019-06-12 2019-07-22 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 2019-06-12 2019-07-22 N
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Health 2019-06-12 2019-07-22 N
Observe each nurse aide's job performance and give regular training. Health 2019-06-12 2019-07-22 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2019-06-12 2019-07-22 N
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Health 2019-06-12 2019-07-22 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 2019-06-12 2019-07-22 N
Provide and implement an infection prevention and control program. Health 2019-06-12 2019-07-22 N
Establish an Emergency Preparedness Program (EP). Fire Safety 2019-06-12 2019-07-22 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2019-06-12 2019-07-22 N
Have simulated fire drills held at unexpected times. Fire Safety 2019-06-12 2019-07-22 N
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Fire Safety 2019-06-12 2019-07-22 N