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Deficiency Records for The Hilltop at Blue River
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.
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 |
| 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 | N |
| Provide activities to meet all resident's needs. | Health | 2021-03-16 | 2021-04-15 | 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 | 2021-03-16 | 2021-04-15 | N |
| 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 |
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