Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hilltop Park Post Acute during CMS and state inspections, most recent first.
Multiple residents reported ongoing issues with food quality, cold meals, and inaccurate meal orders, with complaints repeatedly raised in meetings and to dietary staff. Grievance records showed incomplete documentation and a lack of corrective action, while observations confirmed food was delivered in uninsulated carts with doors left open. Staff interviews acknowledged missed requests and inadequate grievance resolution, resulting in unresolved concerns about meal service.
A resident with paraplegia developed a stage 4 pressure injury with osteomyelitis due to the facility's failure to provide timely pressure relief devices and consistent repositioning. The resident was not given an air mattress until months after the injury developed, and weekly skin assessments were not completed. Nutritional support was also inconsistent, contributing to the worsening of the injury.
The facility failed to ensure nursing staff had the necessary competencies to manage residents' wound care, leading to a resident's pressure wound worsening to Stage 4 with osteomyelitis. The facility lacked documentation of competency assessments for RNs, LPNs, and CNAs, and new leadership had not yet initiated this process.
The facility failed to maintain an effective training program for staff, lacking documentation of required training in QAPI, compliance, ethics, and resident rights. Interviews revealed no QAPI training and inadequate abuse prevention training. CNAs did not receive the required 12 hours of annual in-service training, indicating a significant deficiency in the facility's training program.
The facility violated resident rights by restricting seven residents from leaving without a physician's order, citing safety concerns. Residents felt treated like children and compared the restrictions to being in jail. Staff interviews confirmed the policy, which led to two residents being discharged against medical advice.
The facility failed to properly document and follow procedures for the discharge of three residents. One resident was discharged without physician documentation or a comprehensive care plan, while two others left against medical advice without proper orientation or documentation. Staff interviews revealed a lack of communication and documentation regarding these discharges.
The facility failed to complete discharge summaries for three residents, missing critical information such as medical history, cognitive status, and treatment course. Staff interviews revealed a lack of clarity and responsibility regarding the completion of these summaries, contributing to the deficiency.
The facility failed to provide quarterly financial statements to two residents or their legal representatives, as required by policy. One resident, with intact cognition, and their legal representative did not receive statements despite requests. Another resident, with impaired cognition, and their representatives were not consulted about finances, and no statements were provided since 2018. The Business Office Manager claimed to provide statements and manage funds, but this was not corroborated by the residents or their representatives.
A resident was discharged without receiving a proper notice that included the location of transfer, appeal rights, and notification to the State Long-term Care Ombudsman. The resident, with multiple health conditions, was unaware of their right to appeal. Facility staff showed a lack of awareness and documentation regarding the discharge process, leading to the deficiency.
A resident was discharged from an LTC facility without proper preparation and documentation for his nutritional and tube feeding needs. The discharge summary lacked specific dietary information and was not provided in the resident's preferred language. Interviews revealed that the resident did not receive tube feeding supplies or education, leading to nutritional challenges post-discharge. The DON stated tube feedings were discontinued, but the discharge summary still included instructions for water flushes, indicating a lack of clarity.
The facility failed to effectively document and implement discharge plans for two residents, leading to deficiencies in their discharge processes. One resident, under 65 with a knee fracture and depression, was discharged without a documented plan or physician's order, and expressed frustration over the uncertainty of her discharge. Another resident, 73 with cancer and diabetes, was discharged home without an updated care plan or documented decision-making process. Staff interviews revealed gaps in adherence to the facility's discharge policy, contributing to these deficiencies.
A resident with severe contractures and paraplegia missed crucial medical appointments due to the facility's failure to arrange necessary gurney transportation. Despite the resident's physician's request and the legal representative's notifications, the facility did not secure insurance approval or provide the required transport, citing cost and insurance issues. This inaction led to missed appointments with a urologist and a GI specialist, highlighting a deficiency in the facility's transportation policy adherence.
The facility's QAPI program failed to effectively address pressure injuries, resulting in a repeat deficiency. A resident developed a facility-acquired unstageable pressure injury that progressed to a stage 4 and became infected. Interviews revealed that while pressure injuries were discussed in QAPI meetings, the discussions were not thorough, and the performance improvement plan lacked specific goals.
Failure to Investigate and Resolve Resident Food Grievances
Penalty
Summary
The facility failed to ensure a proper response, action, and rationale to residents involved in group grievances, specifically regarding food quality and meal service. Multiple residents reported ongoing issues with the food, including poor taste, cold temperature, and inaccuracies in meal orders. Residents stated that their complaints were repeatedly brought up in resident council meetings and directly to dietary staff, but no meaningful changes were observed. Observations confirmed that food was delivered in an uninsulated cart with doors left open, contributing to cold meals. A review of grievance records from July to September revealed seven documented complaints related to food and mealtimes, with recurring themes of meal ticket inaccuracy and cold food. The facility's documentation of these grievances was incomplete, with several forms missing investigation and resolution sections. Meeting minutes from food committee and resident council meetings further confirmed that residents' concerns about meal accuracy and temperature persisted, especially during weekends and evenings. There was no evidence of corrective actions or staff training to address these issues. Staff interviews corroborated the lack of effective resolution. The dietary manager acknowledged that residents' food requests were sometimes missed and that it was common for nursing staff to retrieve missing items after trays were delivered. The DON and regional nurse consultant recognized that the facility's response to grievances was inadequate, with the DON expressing disappointment in the lack of documentation and corrective action. The facility's failure to fully investigate, document, and resolve resident grievances regarding food service constituted the deficiency.
Failure to Prevent and Manage Pressure Injury
Penalty
Summary
The facility failed to provide timely and necessary treatment and services to prevent and manage an avoidable, facility-acquired pressure injury for a resident with paraplegia. The resident was admitted with intact skin but developed an unstageable pressure injury on the coccyx 14 days after admission. This injury progressed to a stage 4 pressure injury with osteomyelitis, requiring an extended course of antibiotic treatment. The facility did not provide the resident with pressure relief devices in a timely manner, as an air mattress was ordered over two months after the injury developed and was not implemented until 20 days later. Additionally, the air mattress provided was old, and the facility could not provide documentation on its age or usage. The resident was not routinely repositioned at night unless requested, and the care plan did not include a directive for staff to assist with turning and repositioning until over a month after the pressure injury was assessed as stage 4. Weekly skin assessments were not completed, and physician orders for dressing changes were not followed, with dressing changes not performed in a manner to prevent infection. The facility also failed to ensure the nutritional support ordered for the resident was consistently offered, as the resident did not receive the prescribed double protein diet. Interviews and observations revealed systemic failures in the facility's approach to pressure injury prevention and management. The facility lacked a system to track equipment repairs and did not have the necessary documentation for the air mattress used. The resident's nutritional needs were not adequately addressed, and the interdisciplinary team did not effectively communicate or manage the resident's wound care needs. These deficiencies created an immediate jeopardy situation with the likelihood of serious harm to other residents with similar conditions.
Deficiency in Nursing Staff Competency for Wound Care
Penalty
Summary
The facility failed to ensure that all nursing staff possessed the necessary competencies and skills to manage residents' acute changes in condition, particularly concerning wound development and treatment. This deficiency affected all residents with pressure wounds or those at risk of developing them, contributing to the worsening of a resident's pressure wound to a Stage 4 with osteomyelitis. The facility did not assess the competencies of its RNs, LPNs, and CNAs in critical areas such as wound assessment, care plan development, and the use of pressure-relieving mattresses. The facility's policy on staffing and competency, revised in August 2022, mandates that nursing staff demonstrate skills in basic nursing, skin and wound care, and identifying changes in condition. However, the facility was unable to provide documentation of annual competency assessments for its nursing staff. Interviews revealed that new leadership took over in April 2024 and had not yet initiated the process to assess nursing staff competencies, leading to a gap in ensuring that staff could provide competent care for residents with pressure injuries.
Deficiency in Staff Training Program
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for all staff members, as required by their policy. The policy, dated 2021, mandates that all staff participate in initial orientation and annual in-service training covering various essential topics, including effective communication, resident rights, abuse prevention, and the facility's Quality Assurance and Performance Improvement (QAPI) program. However, the facility was unable to provide documentation that all staff received the required training, particularly in QAPI, compliance and ethics, and resident rights. Additionally, the training records of five randomly selected Certified Nurse Aides (CNAs) revealed that none had received all the required training sessions or the mandated 12 hours of annual in-service training. Interviews with the Nursing Home Administrator (NHA) confirmed that the facility had not provided any staff training on the QAPI program and that the abuse training provided focused only on elder and dependent adult abuse reporting, not on abuse prevention and identification. Furthermore, some staff had not received refresher training on an annual basis, and the NHA acknowledged that the annual CNA training was insufficient. The lack of comprehensive and up-to-date training for staff members indicates a significant deficiency in the facility's training program, which is crucial for ensuring the quality of care and safety of residents.
Violation of Resident Rights and Dignity
Penalty
Summary
The facility failed to uphold resident rights and maintain dignity for seven residents, as observed during a survey. The facility's policy, revised in February 2021, guarantees residents the right to a dignified existence and self-determination. However, during a resident group interview, concerns were raised about restrictions on leaving the facility without a physician's order. Residents expressed feelings of being treated like children and compared the restrictions to being in jail. These concerns were shared by all seven residents interviewed. Staff interviews revealed that the social service director and the nursing home administrator enforced a policy requiring a physician's order for residents to leave the building, citing safety concerns such as the risk of falls. This policy led to two residents being discharged against medical advice when they attempted to leave without the required order. The facility's actions were found to be in violation of resident rights, as they restricted the residents' freedom and self-determination without appropriate justification.
Inadequate Discharge Documentation and Procedures
Penalty
Summary
The facility failed to ensure proper documentation and procedures were followed for the discharge of three residents. Resident #6 was discharged without documentation from a physician regarding the reason for the facility-initiated discharge. The facility did not document the specific needs of the resident that could not be met, the attempts made to meet those needs, or the services available at the receiving facility. Additionally, the discharge planning process was not documented in the resident's electronic medical record (EMR), and necessary information, including the comprehensive care plan goals, was not provided to the receiving facility. Resident #4 was discharged against medical advice (AMA) without signing the AMA release form, and there was no documentation explaining why the resident did not sign it. The facility failed to show that the resident was oriented and prepared for discharge in a manner they could understand. There were no interventions documented to assist the resident in getting to the bank, which was the reason for their desire to leave the facility. Furthermore, there was no physician's order or progress note documenting the reason for the discharge or the needs that could not be met by the facility. Similarly, Resident #3 was discharged AMA without signing the release form, and there was no documentation explaining the lack of signature. The progress notes did not indicate any preparation or orientation for the resident's discharge. There was no physician's order or progress note documenting the reason for the discharge or the needs that could not be met by the facility. The facility's staff interviews revealed a lack of proper documentation and communication regarding the discharges, contributing to the deficiencies identified.
Incomplete Discharge Summaries for Residents
Penalty
Summary
The facility failed to ensure that discharge summaries were properly completed for three residents who were reviewed for discharge. Specifically, the discharge summaries for these residents did not include a recapitulation of their stay or a final summary of their status at the time of discharge. The facility's policy, revised in October 2022, mandates that discharge summaries should include comprehensive information such as the resident's medical history, current diagnoses, treatment course, physical and mental function, and other relevant health details. However, for Resident #2, the discharge summary was incomplete, missing critical information such as physical and mental functional status, cognitive status, dietary and nutritional status, and medical history. For Residents #3 and #4, there was no nursing summary with a recapitulation of their stay completed upon discharge. Interviews with facility staff revealed a lack of clarity and responsibility regarding the completion of discharge summaries. The Regional Nurse Consultant (RNC) confirmed the absence of discharge summaries for Residents #3 and #4 and the incompleteness of Resident #2's summary. The Social Service Director (SSD) indicated that the interdisciplinary team was informed to complete their portions of the discharge summary, which was to be finalized on the day of discharge. However, the Director of Nursing (DON) was unaware that the nurse manager or discharging nurse was responsible for ensuring the completion of the discharge summaries prior to discharge. This lack of communication and accountability contributed to the deficiency in the discharge process for these residents.
Failure to Provide Quarterly Financial Statements to Residents
Penalty
Summary
The facility failed to provide evidence that quarterly financial statements were given to two residents or their legal representatives, as required by their policy on managing residents' personal funds. Resident #9, who had intact cognition, reported not receiving any personal funds statements since admission, and his legal representative confirmed that despite multiple requests and providing documentation of her financial power of attorney (FPOA) status, the facility did not communicate about the resident's finances. The Authorization and Agreement to Manage Resident Funds document for Resident #9 was unsigned by either the resident or the legal representative. Resident #12, who had severely impaired cognition, also did not receive financial statements. The resident's secondary legal representative was not consulted about the finances and was unaware of how funds were spent, despite being involved in care decisions. The primary legal representative, living out of state, relied on the secondary representative for updates and confirmed that no financial statements had been provided since the facility began managing the funds in 2018. The Authorization and Agreement to Manage Resident Funds documents for Resident #12 were also unsigned by the resident or legal representatives. The Business Office Manager (BOM) claimed to provide quarterly statements and notify residents or their representatives when funds needed to be spent down. However, the BOM incorrectly believed Resident #9 had a conservator and was working with a guardian for Resident #12, despite the legal representatives' involvement. The BOM stated that financial statements for the past quarter were provided at the end of July 2024, but this was not corroborated by the residents or their representatives.
Failure to Provide Adequate Discharge Notice and Appeal Information
Penalty
Summary
The facility failed to provide a timely and appropriate notice of discharge to a resident, their representative, and the Office of the State Long-term Care Ombudsman. Specifically, the facility did not issue a discharge notice at least 30 days prior to the resident's discharge. The notice given to the resident lacked essential information, including the location to which the resident was being transferred, the resident's appeal rights, and how to obtain and submit an appeal form. Additionally, the State Long-term Care Ombudsman was not notified of the transfer/discharge. The resident involved, a 66-year-old with multiple diagnoses including hypertension, hypothyroidism, type II diabetes, hemiplegia, and bipolar disorder, was discharged during the survey period. The resident had moderate cognitive impairments and required assistance with daily activities. The resident reported receiving a discharge notice on the same day they complained about staff, and was unaware of their right to appeal the transfer/discharge. The facility's records did not document any behaviors that could not be managed, which would necessitate the transfer/discharge. Interviews with facility staff revealed a lack of awareness and documentation regarding the appeal process and the reasons for the resident's discharge. The Nursing Home Administrator (NHA) admitted to not being aware of the appeal process and relied on the local ombudsman to inform residents of their rights. The facility used two different forms for discharge notices, and there was inconsistency in the documentation and communication regarding the resident's discharge. The facility failed to provide adequate documentation to support the claim that they could not meet the resident's needs, leading to the deficiency.
Inadequate Discharge Preparation for Resident with Feeding Tube
Penalty
Summary
The facility failed to adequately prepare and document the discharge process for a resident, leading to a deficiency in ensuring a safe transition from the nursing home. The resident, who was cognitively intact and required setup assistance with activities of daily living, was discharged without the necessary information and supplies for his nutritional and tube feeding needs. The discharge summary provided to the resident's representative lacked specific dietary and nutritional information, and the instructions were not in the preferred language of Russian, which the resident and his representative spoke. Interviews with the resident's representative and the registered dietitian from the oncologist's office revealed that the resident was not provided with tube feeding supplies or education on how to manage the feeding tube upon discharge. The representative had to obtain supplies from the oncologist's office after discharge, and the resident had lost weight and appeared weak due to inadequate nutrition. The facility's discharge care plan included coordinating medical equipment and providing discharge instructions, but there was no documentation in the electronic medical record indicating that the resident or his representative received training related to the feeding tube. The director of nursing stated that the resident's tube feedings were discontinued prior to discharge because the resident was eating pureed meals. However, the discharge summary still included instructions for water flushes following bolus tube feedings, indicating a lack of clarity and communication regarding the resident's nutritional needs. This oversight resulted in the resident not receiving the necessary support and education for a safe discharge, as evidenced by the resident's subsequent nutritional challenges at home.
Deficient Discharge Planning for Two Residents
Penalty
Summary
The facility failed to develop and implement an effective discharge planning process for two residents, leading to deficiencies in their discharge documentation and planning. Resident #16, who was under 65 years old and had a history of a knee fracture and major depression, was discharged without a documented discharge plan in her electronic medical record (EMR). The resident expressed frustration about the uncertainty of her discharge, and there was no follow-up on her concerns. The facility did not document the reasons for her discharge, the decision-making process, or the involvement of the interdisciplinary team (IDT). Additionally, there was no physician's order for her discharge, which was against the facility's protocol. Resident #2, a 73-year-old with cancer of the tongue, diabetes, and hearing loss, also experienced deficiencies in discharge planning. Although he was discharged home with his wife, the facility failed to update his discharge care plan throughout his stay. His EMR lacked documentation of the discharge plan, the decision-making process, and IDT involvement. While home health care was arranged, the progress notes and care plan did not reflect a safe discharge plan. Interviews with facility staff, including the Director of Nursing (DON) and the Social Service Director (SSD), revealed gaps in the discharge planning process. The DON acknowledged the absence of a physician's order for Resident #16's discharge, and the SSD confirmed the lack of documented discharge plans for both residents. The facility's failure to adhere to its discharge policy and procedure, which requires individualized post-discharge plans and IDT involvement, contributed to these deficiencies.
Failure to Arrange Necessary Medical Transportation
Penalty
Summary
The facility failed to assist a resident with arranging necessary medical transportation, resulting in missed medical appointments. The resident, who is under 65 and has a history of paraplegia, acute transverse myelitis, and other conditions, required transportation via a hospital gurney due to severe contractures in his legs that made sitting in a wheelchair extremely painful. Despite the resident's primary care physician's request for gurney transportation and the resident's legal representative's repeated notifications to the nursing staff, the facility did not secure insurance approval or arrange for the necessary transportation. The resident missed multiple appointments with a urologist and a gastrointestinal specialist, which were crucial due to his medical conditions, including a past bowel obstruction that required surgery and a penile injury from a Foley catheter. The facility's transportation policy, which states that they will assist residents in arranging transportation when necessary, was not followed. The transportation coordinator was aware of the resident's needs but cited the insurance provider's refusal to cover the gurney transport and the facility's unwillingness to pay the $700 cost as reasons for the inaction. Interviews with the transportation coordinator and the regional nurse consultant revealed that the facility should have provided the necessary transportation regardless of insurance coverage. The nursing home administrator was unaware of the resident's inability to tolerate wheelchair transport and the resulting missed appointments. The facility's failure to act on the resident's transportation needs led to the deficiency noted in the report.
Deficiency in QAPI Program for Pressure Injuries
Penalty
Summary
The facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) program was implemented to address compliance concerns, specifically related to pressure injuries. The QAPI program did not identify and address issues effectively, leading to a repeat deficiency in providing treatment and services for pressure injuries. During a recertification survey, it was found that the facility failed to prevent a resident from developing a facility-acquired unstageable pressure injury that progressed to a stage 4 pressure injury and became infected. Interviews with facility staff revealed gaps in the QAPI process. The Medical Director, who attended QAPI meetings, was unaware of the infection in the resident's wounds. The Regional Nurse Consultant acknowledged the need for more involvement with residents who had pressure injuries. The Nursing Home Administrator stated that while pressure injuries were discussed in QAPI meetings, the discussions were not in-depth, and the performance improvement plan lacked specific goals. The facility had a wound physician and an outside consulting company involved, but the QAPI meetings did not fully address the pressure injuries, indicating a lack of comprehensive review and action.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Denver
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Berkley Manor Care Center | 0.6 mi | ★★★★★ | 23 | 0 |
| Crestmoor Care Center | 0.8 mi | ★★★★★ | 1 | 0 |
| Center At Lowry, Llc | 1.2 mi | ★★★★★ | 11 | 0 |
| Lowry Hills Care And Rehabilitation | 2.2 mi | ★★★★★ | 0 | 0 |
| Highland Park Rehabilitation & Care Center | 2.3 mi | ★★★★★ | 0 | 0 |
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