Deficiency Records for Hilltop Heights Health and Rehab Center
Updated as of April 01, 2024
A list of the most recent deficiencies for Hilltop Heights Health and Rehab 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? |
|---|---|---|---|---|
| Implement emergency and standby power systems. | Fire Safety | 2024-01-24 | 2024-03-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-24 | 2024-03-19 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2024-01-24 | 2024-03-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-01-24 | 2024-03-19 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-01-24 | 2024-02-26 | 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 | 2024-01-24 | 2024-02-26 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-01-24 | 2024-02-26 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-01-24 | 2024-02-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-01-24 | 2024-02-26 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2024-01-24 | 2024-02-26 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2024-01-24 | 2024-02-26 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2024-01-24 | 2024-02-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-01-24 | 2024-02-26 | 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 | 2024-01-18 | 2024-02-20 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2024-01-18 | 2024-02-20 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-01-18 | 2024-02-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-18 | 2024-02-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-18 | 2024-02-20 | 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 | 2024-01-18 | 2024-02-20 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-01-18 | 2024-02-20 | 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 | 2024-01-18 | 2024-02-20 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-01-18 | 2024-02-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-19 | 2023-10-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-08 | 2023-09-12 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-08-08 | 2023-09-12 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2023-05-04 | 2023-06-07 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-04 | 2023-05-04 | Y |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-03-15 | 2023-04-06 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-03-15 | 2023-04-06 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-03-03 | 2023-04-05 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-03-03 | 2023-04-05 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-02-02 | 2023-03-22 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-02-02 | 2023-03-22 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-02-02 | 2023-03-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-02 | 2023-03-22 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-02 | 2023-03-22 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-02-02 | 2023-03-22 | 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 | 2023-02-02 | 2023-03-22 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-02-02 | 2023-03-22 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-02-02 | 2023-03-22 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-02-02 | 2023-03-22 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-02-02 | 2023-03-22 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-02-02 | 2023-03-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-02-02 | 2023-03-22 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2023-02-02 | 2023-03-22 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-02-02 | 2023-03-15 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-02-02 | 2023-03-15 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2023-02-02 | 2023-03-15 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-02-02 | 2023-03-15 | 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 | 2023-02-02 | 2023-03-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-02-02 | 2023-03-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-02 | 2023-03-15 | N |
| Have restrictions on the use of flammable curtains. | Fire Safety | 2023-02-02 | 2023-03-15 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-02-02 | 2023-03-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-02-02 | 2023-03-15 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-02-02 | 2023-03-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-08-31 | 2022-09-24 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-03-03 | 2022-04-27 | 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 | 2022-04-27 | 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 | 2022-03-03 | 2022-04-27 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-03-03 | 2022-04-27 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-03-03 | 2022-04-27 | 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 | 2022-03-03 | 2022-04-27 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-03-03 | 2022-04-27 | N |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-03-03 | 2022-04-27 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-11-10 | 2021-12-16 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-09-27 | 2021-10-13 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-27 | Not Fixed | Y |
