Hill View Skilled Nursing and Rehabilitation Cente

Based on observation, staff interview and review of the facility policy, the facility failed to properly store food items to avoid possible contamination. This had the potential to affect all of the residents residing in the facility. The facility census was 69 residents. Findings include: Observation on 06/01/26 at 9:12 A.M. of the kitchen dry storage area revealed there was a large 102 ounce can of vanilla pudding on the shelf with visible dents along the rim of the can. Interview on 06/01/26 at 9:12 A.M. with Director of Dietary Services (DDS) #932 verified the dented can of vanilla pudding should have been sent back as the contents were not suitable for use. Observation on 06/04/26 at 09:45 A.M. of the kitchen dry storage area revealed there were two 102 ounce cans of ketchup both of which were dented along the top seam of the can. Interview on 06/04/26 at 9:45 A.M. with DDS #932 verified the cans should have been returned to the supplier since the cans were dented and should not have been put on the shelf for use. Review of the facility policy titled Food and Supply Purchasing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and staff interview, the facility failed to ensure all kitchen garbage receptacles including outdoor dumpsters were equipped with proper fitting lids to deter animals and pests. This had the potential to affect all of the residents residing in the facility. The facility census was 69 residents. Findings include: Observations on 06/01/26 at 10:20 A.M. and at 2:20 P.M. revealed there were two outside dumpsters near the loading dock which were not covered with lids. Observation on 06/02/26 at 10:51 A.M. with the Administrator revealed the outside dumpsters near the loading dock were not covered with lids. Interview on 06/02/26 at 10:51 A.M. with the Administrator verified the dumpsters did not have lids. The Administrator stated the city had delivered the two dumpsters without lids last week and he had notified the city officials the facility had food service and required lids on all outdoor trash bins. The Administrated stated the lids would be brought out on 06/02/26 or 06/03/26. Observations on 06/03/26 at 09:20 A.M. and at 3:20 P.M. revealed the outside…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review, staff interview, and review of online medication resources, the facility failed to ensure antipsychotic medications were only ordered for an appropriate indication. This affected one (Resident #23) of five residents reviewed for unnecessary medications. The facility census was 69 residents. Findings include: Review of the medical record for Resident #23 revealed an admission date of 06/23/25 with diagnoses including Alzheimer's disease, osteoporosis, and depression. Review of the physician's orders for Resident #23 revealed an order dated 02/24/26 for Zyprexa 2.5 milligrams (mg) one tablet by mouth daily at bedtime for unspecified dementia and an order dated 06/03/26 for Risperdal 0.5 mg three tablets by mouth every morning and every night for a diagnosis of dementia. Review of the Minimum Data Set (MDS) assessment for Resident #23 dated 04/02/26 revealed the resident had severely impaired cognition. Interview on 06/03/26 at 1:13 P.M. with the Director of Nursing (DON) confirmed the facility had administered Zyprexa and Risperdal to Resident #23…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review, observation, and staff interview, the facility failed to ensure a resident with a contracture received care and services to prevent a decline in the contracture. This affected one (Resident #17) of two residents reviewed for limited range of motion. The facility census was 69 residents. Findings include:Review of the medical record for Resident #17 revealed an admission date of 06/20/25 with diagnoses including contracture of the right hand, chronic pain, and dementia. Review of the Minimum Data Set (MDS) assessment for Resident #17 dated 03/30/26 revealed the resident had impaired cognition and had functional limitation in range of motion to one side of the upper extremities. Review of the active care plan for Resident #17 revealed it did not include interventions to prevent a further decline in range of motion or to treat the resident's contractures. Observation on 06/02/26 at 12:52 P.M. revealed Resident #17 was sitting in her room in a wheelchair at her dining table with her right hand closed up in a pinching position. Resident #17 was picking at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, and review of the facility policy, the facility failed to ensure the environment was maintained in good repair. This had the potential to effect all residents residing in the facility. The facility census was 64.Findings include:Observations on 08/08/25 from 10:22 A.M. through 11:30 A.M., during a tour of the facility, revealed a large portion of the ceiling in the second-floor dining room was missing. The area below the missing ceiling had yellow caution tape set up to keep people from walking underneath it. Continued observation of the second-floor hallway, outside of Resident #2's room, revealed discolored ceiling tiles and water was leaking down into a large and a small trash can placed underneath. The ceiling tiles had a black substance on them, which appeared mold or mildew like. Further observation of the third-floor hallway, located outside of Resident #63's room, revealed discolored ceiling tiles from what appeared to be water damage, and the carpet underneath the area was wet. The ceiling vents, located directly inside the doorways of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and staff interview, the facility failed to update the Preadmission Screening and Resident Review (PASARR) with new mental illness diagnoses for residents. This affected two (Residents #28 and #33) of 18 residents reviewed for PASARR completion. The facility census was 53 residents. Findings include: 1.Review of the medical record for Resident #28 revealed an admission date of 10/04/19 with diagnoses including congestive heart failure, hypertension, encephalopathy and major depressive disorder. On 09/07/21 Resident #28 was diagnosed with unspecified psychosis. Review of the admission PASARR document for Resident #28 dated 09/04/19 revealed the had no indications of serious mental illness or developmental disability. Review of the plan of care for Resident #28 dated 02/26/24 revealed the resident had unspecified psychosis with paranoia, hallucinations and increased anxiety. Interventions included the following: monitor and record occurrences of target behavior symptoms such as pacing, wandering, disrobing, inappropriate response to verbal communication,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review, observation, and staff interview the facility failed to provide adequate nail care to dependent residents. This affected one (Resident #13) of five dependent residents reviewed for bathing and nail care. The facility census was 53 residents. Findings include: Review of the medical of the medical record for Resident #13 revealed an admission date of 08/31/22 with diagnoses including congestive heart failure, dementia, and diabetes mellitus type two. Review of the care plan for Resident #13 dated 08/31/22 revealed staff would clean and trim the resident's nails weekly, as needed, and when soiled. Review of the Minimum Data Set (MDS) assessment for Resident #13 dated 04/12/24 revealed the resident was unable to make her needs known as she rarely/never was understood. Resident #13 was dependent on the assistance of staff with bathing and nail care. Review of shower sheet for Resident #13 dated 06/30/24 revealed the resident had received bathing per the schedule with nail care documented as completed 06/30/24. Observation on 06/30/24 at 1:38 P.M. of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, and online guidance, the facility failed to adequately implement care plans and interventions. This affected three residents (#3, #29, and #31) of 20 residents whose care plans were reviewed during the annual survey. The facility census was 49. Findings include: 1. Record review for Resident #29 revealed this resident was admitted to the facility on [DATE] and had diagnoses including atrial fibrillation, stage three chronic kidney disease, hypertension, and systolic heart failure. Review of the admission Minimum Data Set (MDS) assessment, dated 05/03/22, revealed this resident had moderately impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 03. This resident was assessed to require extensive assistance from one staff member for bed mobility, transfers, and toileting. Review of the active care plans for this resident revealed no care plan was implemented for wandering, being at risk for elopement, or the use of a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review and review of the facility policy the facility failed to revise a resident's plan of care to reflect the pressure ulcer prevention device of Prevalon Boots. This affected one of six residents (#12) reviewed for pressure ulcers. The facility census was 49. Findings include: Review of the medical record for Resident #12 revealed an admission date of 07/20/17 with diagnoses including dementia, unspecified psychosis, weakness and chronic obstructive pulmonary disorder. Review of the quarterly Minimum Data Set (3.0) dated 04/08/22 revealed Resident #12 had severe cognitive impairment. Resident #12 was totally dependent on one person for bed mobility, transfers, dressing, toileting, and personal hygiene. Resident #12 had impaired range of motion to bilateral upper extremities. Resident #12 had no skin impairments documented. Review of the physician telephone orders for Resident #12 revealed an order dated 05/03/22 for the resident to wear Prevalon boots while in bed. Staff may remove for dressing and hygiene per resident's tolerance. Review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review and review of facility policy the facility failed to ensure pressure prevention devices were in place as ordered by the physician. The affected two of five residents (#12 and #3) reviewed for pressure ulcers. The facility census was 49. Findings include: 1. Review of the medical record for Resident #3 revealed an admission date of 03/05/22 with diagnoses including osteoarthritis, hypertension, chronic kidney disease, diabetes mellitus and congestive heart failure. Review of the quarterly Minimum Data Set (MDS) 3.0 for Resident #3 dated 06/12/22 revealed the resident had moderate cognitive impairment with no behaviors. Resident #3 required extensive assistance of one person for bed mobility, transfers, dressing, toileting, and personal hygiene. Resident #3 was always incontinent of bowel and bladder. Resident #3 had an unstageable pressure ulcer (defined as full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record reviews, the facility failed to ensure fall interventions were in place as per the plan of care and failed to ensure evidence of monitoring a resident who was at risk for elopement. This affected two residents (#29 and #44) of the five residents reviewed for falls and elopement during the annual survey. The facility census was 49. Findings include: 1. Record review for Resident #29 revealed this resident was admitted to the facility on [DATE] and had diagnoses including atrial fibrillation, stage three chronic kidney disease, hypertension, and systolic heart failure. Review of the admission Minimum Data Set (MDS) assessment, dated 05/03/22, revealed this resident had moderately impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 03. This resident was assessed to require extensive assistance from one staff member for bed mobility, transfers, and toileting. Review of the active care plans for this resident revealed no care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record reviews, and review of facility policies, the facility failed to ensure adequate monitoring of a dialysis residents AV shunt. This affected the one resident (#31) who was receiving dialysis while residing in the facility. The facility census was 49. Findings include: Record review for Resident #31 revealed this resident was admitted to the facility on [DATE] and had diagnoses including stage four chronic kidney disease, dementia without behavioral disturbances, hypertension, and chronic obstructive pulmonary disorder. Review of the admission MDS assessment, dated 04/23/22, revealed this resident had moderately impaired cognation evidenced by a BIMS assessment score of 07. This resident was assessed to require extensive assistance from two staff members for bed mobility and extensive assistance from one staff member for transfers and toileting. Review of the care plan, dated 5/23/22, revealed this resident received dialysis. The only intervention listed was to send a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews the facility failed to provide an appropriate diagnosis for the use of an antipsychotic and failed to discontinue an antianxiety medication due to non-use. This affected two residents(Resident #44 and Resident #201) of five residents reviewed for unnecessary medications. The facility census was 49. Findings include: 1. Record review of Resident #201 on 06/22/22 at 3:28 P.M. revealed this resident was admitted to the facility on [DATE] with the following medical diagnoses: left femur fracture, dysphagia, muscle weakness, anemia, depression, anxiety, hypertension, carotid artery stenosis, gastroenteritis, chronic kidney disease, diarrhea, and transient ischemic attacks. This resident is currently alert and oriented to person, place, and time per admission assessment and nursing notes as this resident does not have an active BIMS score as this resident has been residing in the facility for approximately 2 days. Review of Physician Orders revealed this resident is receiving the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record reviews, and review of facility policies, the facility failed to ensure medications were stored appropriately and provided for the use intended. This affected one resident (#48) out of the 49 residents observed during the annual survey. The facility census was 49. Findings include: Record review for Resident #48 revealed this resident was admitted to the facility on [DATE] and had diagnoses including chronic obstructive pulmonary disease, dementia without behavioral disturbances, anxiety, insomnia, and asthma. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/05/22, revealed this resident had mildly impaired cognition evidenced by a Brief Interview for Mental Status (BIMS) assessment score of 11. This resident was assessed to require extensive assistance from one staff member for bed mobility, transfers, and toileting. Review of the care plan, dated 06/13/22, revealed this resident had asthma and shortness of breath. Interventions included to give…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.