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Deficiency Records for Hilltop Skilled Nsg and Rehab

A list of the most recent deficiencies for Hilltop Skilled Nsg and Rehab. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.

A list of the most recent deficiencies for Hilltop Skilled Nsg and Rehab. 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 all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2024-07-19 2024-08-12 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2024-07-19 2024-08-12 Y
Respond appropriately to all alleged violations. Health 2024-07-19 2024-08-12 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2024-02-26 2024-02-27 Y
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Health 2024-01-27 2024-02-06 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-11-01 2023-12-21 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 2023-10-28 2023-12-20 Y
Provide and implement an infection prevention and control program. Health 2023-10-28 2023-12-20 Y
Reasonably accommodate the needs and preferences of each resident. Health 2023-11-01 2023-12-20 N
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2023-11-01 2023-12-20 N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2023-11-01 2023-12-20 N
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Health 2023-11-01 2023-12-20 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 2023-11-01 2023-12-20 N
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2023-11-01 2023-12-20 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2023-11-01 2023-12-20 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 2023-11-01 2023-12-20 N
Provide enough food/fluids to maintain a resident's health. Health 2023-11-01 2023-12-20 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2023-11-01 2023-12-20 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 2023-11-01 2023-12-20 N
Post nurse staffing information every day. Health 2023-11-01 2023-12-20 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 2023-11-01 2023-12-20 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 2023-11-01 2023-12-20 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2023-11-01 2023-12-20 N
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Health 2023-11-01 2023-12-20 N
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Health 2023-11-01 2023-12-20 N
Provide and implement an infection prevention and control program. Health 2023-11-01 2023-12-20 N
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2023-11-01 2023-12-20 N
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Health 2023-11-01 2023-12-20 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-12-05 2023-12-06 Y
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2023-11-07 2023-11-30 N
Address patient/client population and determine types of services needed. Fire Safety 2023-11-07 2023-11-24 N
Address subsistence needs for staff and patients. Fire Safety 2023-11-07 2023-11-24 N
Establish policies and procedures for volunteers. Fire Safety 2023-11-07 2023-11-24 N
Create arrangements with other facilities to receive patients. Fire Safety 2023-11-07 2023-11-24 N
Establish roles under a Waiver declared by secretary. Fire Safety 2023-11-07 2023-11-24 N
Conduct testing and exercise requirements. Fire Safety 2023-11-07 2023-11-24 N
Implement emergency and standby power systems. Fire Safety 2023-11-07 2023-11-24 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2023-11-07 2023-11-24 N
Have simulated fire drills held at unexpected times. Fire Safety 2023-11-07 2023-11-24 N
Ensure proper usage of power strips and extension cords. Fire Safety 2023-11-07 2023-11-24 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 2023-09-29 2023-10-02 Y
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2023-09-29 2023-09-30 Y
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Health 2023-09-29 2023-09-30 Y
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2023-09-29 2023-09-30 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2023-09-06 2023-09-29 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-08-28 2023-08-31 Y
Provide safe, appropriate pain management for a resident who requires such services. Health 2023-06-07 2023-06-21 Y
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results. Health 2023-06-07 2023-06-21 Y
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2023-06-07 2023-06-21 Y
Make sure that a working call system is available in each resident's bathroom and bathing area. Health 2023-06-07 2023-06-21 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-02-16 2023-03-08 Y
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2022-12-12 2023-02-03 N
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2022-12-27 2023-01-24 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-12-27 2023-01-24 N
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Health 2022-12-27 2023-01-24 N
Provide and implement an infection prevention and control program. Health 2022-12-27 2023-01-24 N
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Health 2022-12-27 2023-01-24 N
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2022-12-27 2023-01-24 Y
Conduct testing and exercise requirements. Fire Safety 2022-12-12 2023-01-19 N
Have properly located and lighted "Exit" signs. Fire Safety 2022-12-12 2023-01-19 N
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2022-12-12 2023-01-19 N
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. Fire Safety 2022-12-12 2023-01-19 N
Properly select, install, inspect, or maintain portable fire extinguishes. Fire Safety 2022-12-12 2023-01-19 N
Install corridor and hallway doors that block smoke. Fire Safety 2022-12-12 2023-01-19 N
Have simulated fire drills held at unexpected times. Fire Safety 2022-12-12 2023-01-19 N
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Fire Safety 2022-12-12 2023-01-19 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2022-09-30 2022-10-03 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2022-09-30 2022-10-03 Y
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Health 2022-09-30 2022-10-03 Y
Provide enough food/fluids to maintain a resident's health. Health 2022-03-09 2022-03-31 Y
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Health 2022-03-09 2022-03-31 Y
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2022-01-27 2022-02-17 Y
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2022-01-27 2022-02-17 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2022-01-27 2022-02-17 Y
Respond appropriately to all alleged violations. Health 2022-01-27 2022-02-17 Y
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2022-01-27 2022-02-17 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2021-10-26 2021-11-12 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2021-11-08 2021-11-11 Y
Install an approved automatic sprinkler system. Fire Safety 2021-10-01 2021-10-07 N
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. Fire Safety 2021-10-01 2021-10-07 N
Ensure that waiting areas, nurse?s stations, gift shops, and cooking facilities, open to the corridor are properly protected. Fire Safety 2021-10-01 2021-10-07 N
Install smoke barrier doors that can resist smoke for at least 20 minutes. Fire Safety 2021-10-01 2021-10-07 N
Provide a written emergency evacuation plan. Fire Safety 2021-10-01 2021-10-07 N
Have proper power supply for life support equipment. Fire Safety 2021-10-01 2021-10-07 N
Keep residents' personal and medical records private and confidential. Health 2021-09-10 2021-10-04 N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2021-09-10 2021-10-04 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 2021-09-10 2021-10-04 N
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2021-09-10 2021-10-04 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2021-09-10 2021-10-04 N
Provide safe and appropriate respiratory care for a resident when needed. Health 2021-09-10 2021-10-04 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2021-09-10 2021-10-04 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 2021-09-10 2021-10-04 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 2021-09-10 2021-10-04 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 2021-09-10 2021-10-04 N
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Health 2021-09-10 2021-10-04 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2021-09-10 2021-10-04 N
Provide and implement an infection prevention and control program. Health 2021-09-10 2021-10-04 N
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Health 2021-09-10 2021-10-04 N

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