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Deficiency Records for Hilltop Healthcare and Rehabilitation Center
A list of the most recent deficiencies for Hilltop Healthcare and Rehabilitation Center. 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 Healthcare and Rehabilitation 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? |
|---|---|---|---|---|
| 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 | 2024-02-01 | 2024-03-14 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-02-01 | 2024-03-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-02-01 | 2024-03-14 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2024-02-01 | 2024-03-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-01 | 2024-03-14 | 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 | 2024-02-01 | 2024-03-14 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-02-01 | 2024-03-14 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2024-02-01 | 2024-03-14 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2024-02-01 | 2024-03-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-02-01 | 2024-03-14 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-02-01 | 2024-03-14 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2024-02-01 | 2024-03-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-01-25 | 2024-03-11 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-01-25 | 2024-03-11 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2024-01-30 | 2024-02-23 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2024-01-30 | 2024-02-23 | 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 | 2024-01-30 | 2024-02-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-30 | 2024-02-23 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-01-30 | 2024-02-23 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2024-01-30 | 2024-02-23 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2024-01-30 | 2024-02-23 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2024-01-30 | 2024-02-23 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-02-24 | 2023-04-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-24 | 2023-04-03 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-24 | 2023-04-03 | 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 | 2023-02-24 | 2023-04-03 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-02-24 | 2023-04-03 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-02-24 | 2023-04-03 | 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 | 2023-02-24 | 2023-04-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-24 | 2023-04-03 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-02-24 | 2023-04-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-02-24 | 2023-04-03 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-02-27 | 2023-04-03 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-02-27 | 2023-04-03 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-02-27 | 2023-04-03 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-02-27 | 2023-04-03 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-02-27 | 2023-04-03 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-02-27 | 2023-04-03 | 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 | 2023-02-27 | 2023-04-03 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-02-27 | 2023-04-03 | 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 | 2023-02-27 | 2023-04-03 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-02-27 | 2023-04-03 | N |
| Construct fire resistant interior walls. | Fire Safety | 2023-02-27 | 2023-04-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-02-27 | 2023-04-03 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-02-27 | 2023-04-03 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2023-02-27 | 2023-04-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-27 | 2023-04-03 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-02-27 | 2023-04-03 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-02-27 | 2023-04-03 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-02-27 | 2023-04-03 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-02-27 | 2023-04-03 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-02-27 | 2023-04-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-02-27 | 2023-04-03 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-02-27 | 2023-04-03 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-02-27 | 2023-04-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-11-04 | 2022-10-31 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-03-24 | 2022-04-27 | 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 | 2022-03-24 | 2022-04-27 | 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 | 2022-03-24 | 2022-04-27 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-03-24 | 2022-04-27 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-03-24 | 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 | 2022-03-24 | 2022-04-27 | 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 | 2022-03-24 | 2022-04-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-24 | 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 | 2022-03-24 | 2022-04-27 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-03-30 | 2022-04-27 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-03-30 | 2022-04-27 | 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 | 2022-03-30 | 2022-04-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-03-30 | 2022-04-27 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2022-03-30 | 2022-04-27 | N |
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