A list of the most recent deficiencies for The Hills Post Acute. 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 exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2024-02-08 | 2024-03-09 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2024-02-08 | 2024-03-09 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-08 | 2024-03-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-02-08 | 2024-03-09 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-02-08 | 2024-03-09 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2024-02-08 | 2024-03-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-02-08 | 2024-03-09 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-02-08 | 2024-02-29 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-02-08 | 2024-02-29 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-02-08 | 2024-02-29 | 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 | 2024-02-08 | 2024-02-29 | 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 | 2024-02-08 | 2024-02-29 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-02-08 | 2024-02-29 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-02-08 | 2024-02-29 | 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 | 2024-02-08 | 2024-02-29 | N |
| Provide activities to meet all resident's needs. | Health | 2024-02-08 | 2024-02-29 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-08 | 2024-02-29 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-02-08 | 2024-02-29 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-02-08 | 2024-02-29 | 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 | 2024-02-08 | 2024-02-29 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2024-02-08 | 2024-02-29 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-02-08 | 2024-02-29 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-02-08 | 2024-02-29 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-02-08 | 2024-02-29 | 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 | 2024-02-08 | 2024-02-29 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-02-08 | 2024-02-29 | 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 | 2024-02-08 | 2024-02-29 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-02-08 | 2024-02-29 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-02-08 | 2024-02-29 | 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 | 2024-02-08 | 2024-02-29 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2024-02-08 | 2024-02-29 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2024-02-08 | 2024-02-29 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-08 | 2024-02-29 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-02-08 | 2024-02-29 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2024-02-08 | 2024-02-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-02-08 | 2024-02-29 | N |
| Implement a program that monitors antibiotic use. | Health | 2024-02-08 | 2024-02-29 | N |
| Regularly inspect all bed frames, mattresses, and bed rails (if any) for safety; and all bed rails and mattresses must attach safely to the bed frame. | Health | 2024-02-08 | 2024-02-29 | N |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2024-02-08 | 2024-02-29 | Y |
| 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 | 2024-02-08 | 2024-02-29 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-08 | 2024-02-29 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-08 | 2024-02-29 | 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 | 2024-02-08 | 2024-02-29 | Y |
| 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 | 2024-02-08 | 2024-02-28 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-01-23 | 2024-02-22 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2024-01-23 | 2024-02-22 | Y |
| 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 | 2024-01-23 | 2024-02-22 | Y |
| 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 | 2024-01-23 | 2024-02-22 | Y |
| 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 | 2024-01-23 | 2024-02-22 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-01-23 | 2024-02-22 | Y |
| Prepare residents for a safe transfer or discharge from the nursing home. | Health | 2024-01-23 | 2024-02-22 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-01-23 | 2024-02-22 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2024-01-23 | 2024-02-22 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-23 | 2024-02-22 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-01-23 | 2024-02-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-23 | 2024-02-22 | Y |
| 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 | 2024-01-23 | 2024-02-22 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-01-23 | 2024-02-22 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-01-23 | 2024-02-22 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-01-23 | 2024-02-22 | Y |
| 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 | 2024-01-23 | 2024-02-22 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-01-23 | 2024-02-22 | Y |
| Dispose of garbage and refuse properly. | Health | 2024-01-23 | 2024-02-22 | Y |
| 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 | 2023-12-28 | 2024-01-27 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-12-28 | 2024-01-27 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-28 | 2024-01-27 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-12-28 | 2024-01-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-12-28 | 2024-01-27 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-11-30 | 2023-12-15 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-11-30 | 2023-12-15 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-10-18 | 2023-11-09 | Y |
| 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 | 2023-10-18 | 2023-11-09 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-18 | 2023-11-09 | Y |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2023-10-18 | 2023-11-09 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-13 | 2023-10-08 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-09-13 | 2023-10-08 | 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 | 2023-09-13 | 2023-10-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-16 | 2023-09-08 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-08-16 | 2023-09-08 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-16 | 2023-09-08 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-08-16 | 2023-09-08 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-06-15 | 2023-07-14 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-06-14 | 2023-07-14 | Y |
| 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 | 2023-06-14 | 2023-07-14 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-05-03 | 2023-06-01 | Y |
| 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 | 2023-05-03 | 2023-06-01 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-04-13 | 2023-05-12 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-04-14 | 2023-05-05 | 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 | 2023-04-14 | 2023-05-05 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-02-09 | 2023-03-07 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-02-02 | 2023-03-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-12-30 | 2023-01-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-12-30 | 2023-01-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-12-30 | 2023-01-13 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-12-01 | 2022-12-19 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-22 | 2022-12-15 | Y |
| Provide activities to meet all resident's needs. | Health | 2022-11-18 | 2022-12-11 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-10-10 | 2022-11-04 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-10-10 | 2022-11-04 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-09-26 | 2022-10-26 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-09-22 | 2022-10-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-08-30 | 2022-09-30 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-25 | 2022-09-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-25 | 2022-09-25 | Y |
| 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 | 2022-03-01 | 2022-03-18 | Y |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2022-03-01 | 2022-03-18 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-01-31 | 2022-02-12 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-01-31 | 2022-02-12 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2021-10-18 | 2021-11-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-10-18 | 2021-11-10 | 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 | 2021-10-18 | 2021-11-10 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-10-18 | 2021-11-10 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-10-18 | 2021-11-10 | N |
| 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 | 2021-10-18 | 2021-11-10 | N |
| Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. | Health | 2021-10-18 | 2021-11-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-10-18 | 2021-11-10 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-10-18 | 2021-11-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-18 | 2021-11-10 | Y |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-10-18 | 2021-11-02 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2021-10-18 | 2021-11-02 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-10-18 | 2021-11-02 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-10-18 | 2021-11-02 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2021-10-18 | 2021-11-02 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-10-18 | 2021-11-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-17 | 2021-10-10 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-09-10 | 2021-09-29 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-09-07 | 2021-09-23 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-07-15 | 2021-08-02 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2021-05-14 | 2021-06-14 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-04-13 | 2021-05-13 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2021-04-13 | 2021-05-13 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2021-04-13 | 2021-05-13 | 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 | 2021-04-13 | 2021-05-13 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2021-04-13 | 2021-05-13 | 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 | 2021-04-13 | 2021-05-13 | N |
| Respond appropriately to all alleged violations. | Health | 2021-04-13 | 2021-05-13 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-04-13 | 2021-05-13 | 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 | 2021-04-13 | 2021-05-13 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-04-13 | 2021-05-13 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-13 | 2021-05-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-13 | 2021-05-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-13 | 2021-05-13 | 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 | 2021-04-13 | 2021-05-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-04-13 | 2021-05-13 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-04-13 | 2021-05-13 | 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 | 2021-04-13 | 2021-05-13 | N |
| 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 | 2021-04-13 | 2021-05-13 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-04-13 | 2021-05-13 | 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 | 2021-04-13 | 2021-05-13 | 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 | 2021-04-13 | 2021-05-13 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-04-13 | 2021-05-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-04-13 | 2021-05-13 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-04-16 | 2021-05-03 | Y |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-04-13 | 2021-04-26 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-04-13 | 2021-04-26 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2021-04-13 | 2021-04-26 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2021-04-13 | 2021-04-26 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-04-13 | 2021-04-26 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2021-04-13 | 2021-04-26 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-04-13 | 2021-04-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-04-13 | 2021-04-26 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-04-13 | 2021-04-26 | N |
