The Hills Nursing & Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review the facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal care for 2 of 8 residents (Residents #13, and 55) reviewed for ADL care. The facility failed to ensure nail care, to include trimming and cleaning, was provided to Residents #13, and #55. The failure placed the residents at risk of hygiene and safety risks such as nail tearing, injury, and functional difficulties. Findings included: 1.Record review of Resident #13's Face Sheet, dated 02/26/26, reflected a [AGE] year-old male who admitted to the facility on [DATE]. Record review of Resident #13's Quarterly MDS, dated [DATE], reflected the resident had diagnoses that included: Cerebral Infarction with hemiplegia (Stroke resulting in paralysis of one side of body), Diabetes Mellitus (chronic condition in which the body does not regulate blood sugar levels), Lack of coordination, and unspecified…

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, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 8 residents (Resident #86) and 1 of 3 staff (HA C) reviewed for infection control. 1. A medical equipment provider failed to put on PPE prior to entering Resident #86's room, while the resident was on isolation for COVID-19. 2. The facility failed to ensure HA C performed hand hygiene between residents while passing meal trays on E Hall.This failure could place residents at risk of being infected by staff/providers in contact with other residents with infections. Findings included: 1. Review of Resident #86's admission MDS dated [DATE] reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. The residents' diagnoses included cancer, atrial fibrillation (rapid, irregular,…

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 interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 8 residents (Resident #12) reviewed for care plans. The facility failed to ensure Resident #12's comprehensive care plan was updated to reflect his G-tube was changed in-house, as required. This failure could place the residents at risk of not receiving the necessary care and services needed. Findings included: Record review of Resident #12's Face Sheet, dated 02/26/26, reflected he was a [AGE] year-old male who admitted to the facility on [DATE] and readmitted on [DATE]. Record review of Resident #12's Quarterly MDS Assessment, dated 12/2/25, reflected the resident had the following diagnoses: Cerebral Palsy (neurological disorder caused by damage to…

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, and record review, the facility failed to ensure a resident with a pressure ulcer received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (Resident #61) of three residents reviewed for pressure ulcers.The Wound Care Nurse failed to re-clean the wound to Resident #61's right heel after she put his foot down on the bed with the wound exposed to the drawsheet under the resident. This failure could place residents at risk for deterioration of existing wounds/skin injuries. Findings included:Review of Resident #61's quarterly MDS dated [DATE] reflected the resident was an [AGE] year-old male admitted to the facility on [DATE]. The residents' diagnoses included heart failure, paraplegia, cognitive communication deficit, pressure ulcer of right buttock, and pressure ulcer of right heel. Resident #61 had a BIMS of 6 which indicated his cognition was severely…

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, and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for three of six residents (Residents #1, #3 and #2) reviewed for abuse.1. The facility failed to ensure Resident #3 did not kiss Resident #1 without her consent on 05/23/25.2. The facility failed to ensure LVN G did not yell at Resident #2. These failures could place residents at risk for injury or psychosocial harm. Findings included:1. Record review of Resident #1's admission Record, dated 07/17/25, reflected a [AGE] year-old female who admitted to the facility on [DATE].Record review of Resident #1's Quarterly MDS Assessment, dated 07/01/25, reflected she had a BIMS score of 06, which indicated moderate cognitive impairment. Her active diagnoses included non-Alzheimer's dementia (the loss of memory and other intellectual functions severe enough to cause problems in one's abilities to perform daily activities), anxiety…

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 interview and record review, the facility failed to immediately notify the resident's representative when there was a need to alter treatment for 1 of 3 residents (Resident #1) reviewed for notification of change. The facility failed to notify Resident #1's representative when the medication, Pramipexole (Mirapex), was added to her drug regimen on 01/01/25 to treat restless leg syndrome. This failure could place residents at risk for a delay in treatment and not receiving proper care due to failure to notify resident representative. Findings included: Record review of Resident #1's admission MDS assessment dated [DATE] reflected the resident was [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included coronary artery disease (a condition where the arteries that supply blood to the heart become narrowed or blocked), high blood pressure, hemiplegia (a condition that causes weakness or paralysis to one side of the body), anxiety disorder, depression, and pain. Resident #1 had a BIMS…

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, and record review, the facility failed to prepare, store, distribute, and serve foods in accordance with professional standards for food service safety in the facility's only kitchen. The facility failed to ensure pork chops stored in the facility freezer were covered to prevent contamination. This failure placed residents, who received food from the kitchen, at risk for food contamination and food borne illness. Findings included: Observation of the facility freezer on 11/18/24 at 9:04 AM revealed uncovered pork chops stored in a labeled, metal pan. Interview on 11/20/24 at 3:34 PM with the [NAME] revealed all items in the facility refrigerators and freezers should be covered, labeled, and dated. The [NAME] stated the importance of covering foods was to prevent contamination. The [NAME] added that residents could get sick if they ate contaminated food. The [NAME] said he would report uncovered, labeled, and dated to his dietary manager. The [NAME] stated he was last in-serviced on food storage about a month ago. Interview on 11/20/24 at 3:37 PM with…

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 and record review, the facility failed to ensure each resident was treated with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 6 residents (Resident #3) reviewed for dignity. The facility failed to allow Residents #31 to keep his electric wheelchair when he admitted to the facility. This failure could place residents at risk for a loss of dignity, decreased self-worth and decreased self-esteem. Findings included: Record review of Resident #31's quarterly MDS, dated [DATE], reflected the resident was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included heart disease, end stage renal disease (a terminal illness that occurs when the kidneys can no longer function properly), and stroke. Resident #31 had a BIMS of 12 which indicated his cognition was moderately impaired. The MDS further indicated the resident had impairment on one side to his…

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, and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice for 1 of 2 residents (Resident #47) reviewed for dialysis. The facility failed to ensure post-dialysis assessments were completed for Resident #47 after they returned from dialysis treatment. This failure could place residents at risk of inadequate post dialysis care resulting in harm to the resident. Findings included: Record review of Resident #47's face sheet, dated 11/20/24, reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #47 had diagnoses which included encephalopathy (brain disease that alters brain function or structure), end stage renal disease (when kidneys suddenly become unable to filter waste products from blood), acute kidney failure, fluid overload, and difficulty in walking. Record review of Resident #47's Nursing Home PA PPS Discharge Item Set, dated…

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, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments for 1 of 4 medication carts (Hall C Medication Cart) reviewed for storage, in that: MA A failed to ensure the Hall C Medication cart was locked when she left it unattended for approximately two minutes. This deficient practice placed residents at risk of misappropriation of medications or harm due to accidental ingestion of unprescribed medications. Findings included: Observation on 11/19/24 at 8:00 AM revealed the Hall C medication cart was observed unlocked and unattended on Hall C outside of the dining room for approximately two minutes. The medication cart was not within view of the dining room. Approximately 100 different types of medications including medications such as antihypertensives, anticonvulsants, and anticoagulants, were accessible inside the unlocked cart including medications in blister packs, bottles, and vials. The narcotics were noted as locked in a drawer with a second lock and were not accessible. MA A returned to 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 interview and record review, the facility failed to ensure the residents comprehensive care plan was reviewed and revised after each assessment, including both the comprehensive and quarterly review assessments for 3 of 14 residents (Residents #5, #7 and #104) reviewed for care plans, in that: The facility failed to ensure Residents #5, #7, #104's selected resuscitaiton statuses were updated on their care plans. This deficient practice could affect residents at the facility and place them at-risk of their advanced directives not being honored. Findings included: Review of Resident #5's face sheet, dated 09/28/23, revealed the resident was an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease with (acute) exacerbation, essential hypertension (high blood pressure), acute respiratory failure with hypoxia (low oxygen), and pneumonia. Resident #5 face sheet reflected advance directive of DNR. Review 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 observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Residents #121 and #122) of ten residents observed during medication pass. Reviewed for infection control, in that: 1. Medication Aide C failed to clean the blood pressure wrist cuff after checking vitals of Residents #121 and #122. 2. Medication Aide C failed to disinfect the medication cart prior to it being used. These failures could affect the 4 residents on the Quarantine Hall who received medications by Medication Aide C by placing them at risk for spread of infection through cross-contamination of pathogens and illness. Findings included: Record review of Resident #121's undated face sheet, revealed that of a [AGE] year-old white female admitted [DATE] with a history that included Cerebrovascular…

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, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings for 1 of 2 residents (Resident #12) reviewed for tube feeding. The facility failed to follow physician order's for Resident #12 when cleaning the resident's enteral stoma site by not applying a gauze dressing. This deficient practice could place residents who require enteral feedings at risk for weight loss, dehydration, metabolic abnormalities, and hospitalizations. Findings included: Record review of Resident #12's quarterly MDS assessment, dated 07/01/23, revealed the resident was an [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included dysphagia oropharyngeal phase (difficulty swallowing) and gastrostomy status (surgical opening into the stomach). MDS revealed a BIMS score of 0 which indicated Resident #12 had severe cognitive impairment. 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 observation, interview, and record review, the facility failed to ensure that residents were provided with respiratory care consistent with professional standards for 1 of 6 residents (Residents #5) reviewed for respiratory care in that: Resident #5's humidifier bottle attached to the oxygen concentrator was empty and had not been changed since 09/17/23. These deficient practices could affect residents who received oxygen with inadequate oxygen support, infections and could result in a decline in health. Findings included: Review of Resident #5's face sheet, dated 09/28/23, revealed the resident was an [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included chronic obstructive pulmonary disease with acute exacerbation, acute respiratory failure with hypoxia, and pneumonia. Review of Resident #5's quarterly MDS assessment, dated 07/23/23, revealed the resident had a BIMS score of 15, which indicated the resident was cognitively intact. 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.