Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 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.
Menu portion sizes were not followed during a lunch meal when a cook used scoops and a ladle that did not match the documented diet extensions. Mashed potatoes, carrots, and ham were served in smaller or different portions than required for regular, soft and bite size, mince and moist, and puree diets, and the RD and DM confirmed the cook used smaller scoops because of the smaller pan size and lower volume of food.
Surveyors found that resident rooms and shower areas were not maintained in a clean, comfortable, and homelike condition. Observations showed dust, cobwebs, debris, peeling wallpaper, damaged doors, and dirty or broken wall AC units in resident rooms, while shower rooms had leaking ceilings, wet and warped flooring, missing and cracked tile, damaged walls, and shower heads wrapped with coban. Residents and staff confirmed several of the issues, including a broken door, dust blowing from an AC unit, and a shower head that was broken and difficult to use.
Medication labeling and storage were deficient in multiple med carts. An LPN and the infection preventionist found morphine sulfate oral solution, insulin lispro, and inhalers stored in medication boxes, but the individual containers were not labeled with the resident’s name and, when applicable, the date opened. One resident’s discontinued narcotic medications also remained in the cart after the resident expired, and the DON stated the handwritten label on the insulin vial was not appropriate.
Improper Hand Hygiene and Glove Use During Meal Prep: A dietary aide repeatedly handled ready-to-eat foods, meal tickets, plates, bread bags, and utensils with the same single-use gloves while preparing and serving lunch items, without washing hands or changing gloves between tasks. The DM and RD stated staff should wash hands and change gloves when changing tasks or after leaving the task, and noted recent hand hygiene and glove-use training.
The facility failed to maintain infection control practices during room cleaning, EBP care, and access to the soiled linen room. Housekeepers did not consistently disinfect high-touch surfaces, did not keep BNC-15 wet for the required dwell time, did not use proper glove and hand hygiene practices, and did not follow cleaning procedures in shared rooms and bathrooms. CNAs also provided incontinence care, transfers, showers, and care for residents with catheters and tube feeds without the required gowns under EBP, and residents were observed entering the soiled linen room and looking through bagged soiled linens.
The facility failed to complete and document discharge planning for two residents. One resident's record did not clearly document the discharge reason, the discharge location was inconsistent across records, and the EMR did not show the reconciled med list and care plan as part of the discharge documentation. For the other resident, the care plan was not updated to reflect a preference to transfer to another SNF, and the EMR lacked documentation of discharge preparation in a form the resident could understand.
Failure to maintain resident privacy occurred when a cognitively intact resident with significant care needs was transported from the shower room in a shower chair without being fully covered, leaving parts of her body visible, and when another resident with severe cognitive impairment received incontinence care with the room door open, privacy curtains not drawn, and window blinds open. Staff interviews confirmed that the door and curtains should have been closed and residents should have been completely covered during shower transport and personal care.
A resident with cognitive intactness and documented vision diagnoses did not receive prescribed bifocal eyeglasses after an optometry visit. The resident reported waiting months for glasses and was repeatedly observed without them, while the record showed the prescription was on file but there was no documentation that the lenses were provided. Staff interviews showed unclear follow-up and communication between nursing, social services, and the appointment scheduler, and the care plan did not include a person-centered plan for the resident’s eyeglasses.
A resident with an indwelling Foley, hx of UTI, sepsis, BPH, and bladder dysfunction had a traumatic catheter change that caused bleeding and led to hospital transfer. The record showed the urology order for monthly catheter changes was not entered into the EMR, the catheter was not changed timely, and hospital documentation linked the event to hematuria, SVT, sepsis criteria, ESBL UTI, and MRSA bacteremia. Staff interviews confirmed the catheter was overdue and that the monthly urology order was not known.
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.
Menu Portion Sizes Not Followed
Penalty
Summary
The facility failed to ensure menus met residents’ nutritional needs and were followed, as the posted menu extensions did not match the portion sizes actually served at lunch. The menu for pineapple glazed ham, mashed potatoes, sliced parsley carrots, and orange dream cake specified different serving sizes by diet texture, including three ounces of ham for the regular diet, one half cup of mashed potatoes for regular, soft and bite size, mince and moist, and puree diets, one half cup of parsley carrots for regular and soft and bite size diets, and one third cup of pureed carrots for the puree diet. During the lunch meal observation, the cook used scoops and a ladle that did not correspond to those documented portions, including a #12 green scoop for mashed potatoes and ham and a #16 blue scoop for puree and minced and moist items. Meal service observations showed mashed potatoes were served with the #12 green scoop for regular, mince and moist, soft and bite size, and puree diets even though the menu extensions called for one half cup portions. Parslied carrots were served with a three-ounce ladle for regular and soft and bite size diets instead of one half cup portions. Ham was served with the #12 green scoop for soft and bite size diets instead of one half cup. Ham and carrots were served with the #16 blue scoop for mince and moist and puree diets instead of the documented one half cup ham portions and the one half cup or one third cup carrot portions required by the menu extensions. The RD and DM stated the cook used smaller scoops because of the smaller volume of food and pan size, and the RD noted that smaller portions could result in less food being served over time.
Unsafe and Unclean Resident Rooms and Shower Areas
Penalty
Summary
The facility failed to provide a comfortable and homelike environment in resident rooms and shower areas. The facility policy stated that residents are to be provided with a safe, clean, comfortable, and homelike environment, and that resident rooms are to be cleaned regularly and as needed, with blinds, curtains, and windows checked and cleaned if necessary. Despite this, surveyors observed multiple resident rooms with dust, cobwebs, debris, peeling wallpaper, damaged walls, and broken room features. In one resident room, the blinds were coated with visible dust and cobwebs, and dead bugs were found in the window sill. In another room, the window sill had a layer of dust and the wall air conditioner contained dust and small pieces of debris. Another room had multiple brown spots on the wall behind the bed, and a bathroom wall had missing and peeling wallpaper around the perimeter. Additional observations included a hole in a bathroom door, a missing door bolt, latch, and face plate with broken wood around the handle, cobwebs in a windowsill, black pinpoint spots and peeling wallpaper on window jambs, and dust and debris inside a wall air conditioner. Resident interviews confirmed concerns with these conditions, including a resident who said the blinds did not block the sun, another who said dust from the wall air conditioner blew onto her wheelchair, and another who reported a broken door that had gotten stuck closed. The facility also failed to keep shower rooms and spas in good working condition. In one shower room, the ceiling tile was stained and drooping, the wall paint was bubbling and damp, the floor was warped and soft, tile was missing from the baseboard area, the wall was damaged with gouges and missing sections, and the shower stall floor was wet from a leak in the ceiling with cracked tile inside the stall. In another shower room, shower heads and holders in two stalls were wrapped with coban, and in a third shower room there was a visible gap in the caulking where floor tile met wall tile. A resident with a nephrostomy site reported that the shower head in the shower room was broken and wrapped with coban, and that she had to hold the shower head up while showering. Staff and maintenance interviews confirmed awareness of several of these conditions, including damaged walls, missing tiles, a ceiling leak, and shower heads and holders that were on back order.
Medication Labeling and Storage Deficiencies
Penalty
Summary
Drugs and biologicals were not properly labeled and stored in three medication carts. During observations, a bottle of morphine sulfate oral solution for one resident was stored in a medication box, but the individual bottle was not labeled with the resident’s name or the date it was opened. A vial of insulin lispro had its pharmacy label destroyed, the box was labeled with a marker, and the vial itself was not labeled with the resident’s name or the date opened. In another cart, three bottles of morphine sulfate oral solution were stored in labeled boxes, but the bottles inside were not labeled with the resident’s name or the dates opened, and discontinued narcotic medications for one resident remained in the cart after the resident had expired. An inhaler for another resident was also stored in a labeled box, but the inhaler itself was not labeled with the resident’s name. In a third medication cart, an inhaler was stored in an appropriately labeled medication box, but the inhaler was not labeled with the resident’s name. Staff interviews confirmed the labeling concerns, with an LPN stating the individual medication bottles needed labels in case the box was damaged or lost. The DON stated the handwritten label on the insulin vial was not appropriate, that medications should be removed from carts after a resident expires, and that narcotics should be removed within 24 hours of expiration.
Improper Hand Hygiene and Glove Use During Meal Preparation
Penalty
Summary
The facility failed to store, prepare, and distribute food in a sanitary manner in the main kitchen because dietary aide #1 did not wash hands or change single-use gloves appropriately while preparing, plating, and distributing ready-to-eat food. During a continuous observation of the lunch meal, the aide repeatedly handled ready-to-eat items, meal tickets, plates, bread bags, and food preparation equipment while wearing the same pair of black single-use gloves for extended periods. At 10:55 a.m., the aide cut a sandwich, handled a meal ticket, pulled bread from a bag, separated deli meat, removed cheese from a pan, and picked up plates without washing hands or changing gloves after changing tasks or after soiling the gloves. At 11:05 a.m. and 11:09 a.m., the aide continued using the same gloves while placing and cutting sandwiches, handling meal tickets, opening bread bags, placing bread in the toaster, and reading through tickets. The aide later removed gloves to wash hands and then donned new gloves. The same pattern continued throughout the meal service. At 11:15 a.m., 11:19 a.m., 11:20 a.m., 11:25 a.m., 11:28 a.m., 11:33 a.m., 11:36 a.m., 11:45 a.m., 11:50 a.m., 11:55 a.m., and 11:59 a.m., the aide repeatedly handled meal tickets, bread bags, plates, lettuce, tomato, cheese, pickles, bacon, omelets, sandwiches, and buns while wearing the same gloves, with no handwashing or glove change between tasks. The dietary manager and regional clinical resource/registered dietitian stated that staff should wash hands and change gloves when changing tasks or after walking away from the task, and the regional clinical resource said staff had recently received handwashing and glove-use training.
Infection Control Failures in Room Cleaning, EBP Use, and Soiled Linen Access
Penalty
Summary
The facility failed to maintain an infection prevention and control program on two of four units. During observations, housekeepers did not consistently clean high-touch surfaces, did not use disinfectant in a way that allowed the required dwell time, did not use proper cleaning techniques, and did not perform hand hygiene at the appropriate times while cleaning resident rooms. In a double-occupancy room, one housekeeper swept both sides of the room, handled items such as a box of tissues and pillows, and then used a rag sprayed only a few times with BNC-15 to wipe surfaces that remained visibly wet for five seconds or less. High-touch items such as call lights and bed remotes were not disinfected, separate rags were not used for each side of the room, and the same mop pad was used across both sides of the room before being changed. In a single-occupancy room, another housekeeper sprayed BNC-15 on bathroom surfaces while the resident’s toothbrush and toothpaste remained on the sink counter, did not disinfect call lights or bed remotes, and again did not keep surfaces wet for the three-minute dwell time. The observations also showed improper handling of bathroom cleaning tasks. One housekeeper cleaned the toilet, tapped the toilet brush on the rim of the toilet, and then returned it to its receptacle. The housekeeping supervisor stated that housekeepers should saturate rags with disinfectant, clean all high-touch areas, use different rags for double-occupancy rooms, use different mop pads for each side of the room, and should not tap the toilet brush on the toilet. The supervisor also stated that staff should remove gloves and perform hand hygiene after cleaning the toilet and bathroom and should not spray disinfectant near residents’ personal hygiene items. Another housekeeper failed to change gloves after cleaning the toilet and before continuing other cleaning tasks. The facility also failed to ensure staff followed enhanced barrier precautions for residents who had an indwelling catheter or an enteral tube feed. Two CNAs provided incontinence care and transferred a resident with an indwelling catheter without wearing gowns, and another CNA assisted a resident with an enteral tube feed without donning a gown. Staff interviews showed that one CNA did not believe gowns were needed for catheter care, showers, incontinence care, tube feeds, or wounds, while the DON stated that EBP should be followed for residents with wounds, catheters, and tube feeds and that staff should wear at least gowns and gloves. In addition, residents were observed entering the soiled linen room and looking through bagged soiled linens. One resident helped open the coded door, and another resident was allowed to stand at the open door and look through the bags while a CNA held the door open. The DON stated that residents should not be in the soiled linen room and should not be looking through bagged soiled linens.
Discharge planning and transfer documentation were incomplete for two residents
Penalty
Summary
The facility failed to revise and implement effective discharge planning for two residents, including documentation of the discharge process, the reason for discharge, and the required discharge paperwork provided at transfer or discharge. For one resident, the record did not consistently reflect the discharge location, and the discharge summary documented a home/community discharge with the reason listed only as "other," without additional explanation. The record also did not include documentation of the reconciled medication list and care plan in the discharge summary, and the resident's receipt signature was present without a date. Staff interviews indicated the resident had been told she had community Medicaid and that her niece would take her home, but the EMR still contained notes indicating the resident was in the hospital after discharge. The first resident had diagnoses including acute respiratory failure, myocardial infarction, end stage renal disease, congestive heart failure, vascular dementia, and metabolic encephalopathy. The MDS documented the resident as cognitively intact for decision-making, needing partial to moderate assistance with ADLs, and having an unplanned discharge to a short-term general hospital, although other documentation and staff statements indicated discharge home. The discharge care plan had been developed for long-term care and included interventions related to IDT discharge planning, but the discharge summary did not document the reason for discharge in a clear manner or show the required discharge documents as part of the record. For the second resident, the facility did not update the discharge care plan to reflect the resident's preference to transfer to another facility, and the EMR lacked documentation of preparation provided before transfer in a form and manner the resident could understand. This resident had diagnoses including chronic respiratory failure with hypoxia, malignant neoplasm of connective and soft tissue of the right lower limb, and hypothyroidism, and the MDS documented the resident as cognitively intact with a BIMS score of 14 and needing moderate to substantial assistance with most ADLs. The discharge was planned and documented as a transfer to another SNF for resident preference, but the discharge summary did not include the reconciled medication list or care plan, and the record lacked follow-up documentation supporting the discharge planning discussions noted by staff.
Failure to Maintain Resident Privacy During Care and Transport
Penalty
Summary
Keep residents' personal and medical records private and confidential was not maintained when two residents were not provided privacy during care and transport. Resident #150, who had multiple sclerosis, a gastrostomy status, epilepsy, and a history of cerebral infarction, was cognitively intact with a BIMS score of 15 and required substantial to maximal assistance with showering, toileting, and dressing. She stated that she sometimes had to remind staff to close her door, pull the curtain, and keep her fully covered, and she described being naked under a sheet while being pushed in the hallway to the shower room. During observation, she was transported from the shower room back to her room in a shower chair with the sheet pulled up only around her left elbow, leaving her left breast and stomach visible. Resident #2, who had an indwelling urethral catheter, Alzheimer's disease, metabolic encephalopathy, and acute respiratory failure with hypoxia, was rarely or never understood through staff assessment and had severe cognitive impairment with dependence on staff for all ADLs. During observation, two CNAs were providing incontinence care while the roommate had left the room door open with a magnetized prop, the resident was visible from the hallway, the privacy curtains were not drawn, and the window blinds were open. The door remained open for approximately 30 seconds to one minute while care was being provided.
Delay in Providing Prescribed Eyeglasses
Penalty
Summary
The facility failed to ensure Resident #105 received her prescription eyeglasses in a timely manner after an optometrist wrote the prescription. Resident #105, who was cognitively intact with a BIMS score of 13 out of 15 and had diagnoses including type 2 diabetes mellitus, was admitted to the facility and later evaluated by optometry for vision needs. The optometry note documented that she had early cataracts, regular astigmatism, hypermetropia, presbyopia, and age-related nuclear cataracts bilaterally, and a bifocal eyeglass prescription was issued. Resident #105 told surveyors she had been waiting about three months for new glasses and was observed multiple times without wearing glasses. During an interview, she asked staff whether they had contacted the eye doctor, and later stated that the optometrist did not provide her glasses or an update while at the facility. Review of the record showed the facility had the eyeglass prescription, but there was no further documentation showing that the prescription bifocal lenses were received or provided to the resident. The resident’s comprehensive care plan did not include a person-centered plan for her prescription eyeglasses. Staff interviews indicated that nursing and social services were expected to communicate about new eyeglasses and that the appointment scheduler and social services director were involved in ancillary follow-up, but multiple staff members said they were unaware that Resident #105 was supposed to wear glasses. The director of nursing stated the business office manager was ordering the prescription eyeglasses at the time of survey review, and the nursing home administrator later provided a receipt showing the glasses were ordered after survey exit.
Delayed Foley Change and Traumatic Catheter Insertion
Penalty
Summary
The facility failed to provide appropriate catheter care for a resident with an indwelling urinary catheter and failed to ensure the catheter was changed timely. The resident had a history of UTI, sepsis, benign prostatic hyperplasia with lower urinary tract symptoms, neuromuscular dysfunction of the bladder, and epididymitis. The resident’s MDS showed moderate cognitive impairment, substantial/maximal assistance needed for toileting, partial/moderate assistance with mobility, and use of an indwelling catheter. The resident reported that the catheter had not been changed for a long time and described severe pain during a catheter change. He stated that during the catheter insertion he screamed, asked the nurse to stop and slow down, and later woke up covered in blood. The nursing record documented that the catheter was changed and that bleeding was noted after insertion, with the catheter draining urine mixed with blood. The resident was sent to the hospital after the traumatic catheter replacement. Record review showed a urologist order for a 16 Fr Foley catheter with 5 ml balloon inflation to be changed once per month, but the facility did not enter that order into the EMR. The EMR also showed a later catheter order that was PRN for dislodging, leaking, obstruction, or clogging. Review of the record indicated the catheter had not been changed for more than 30 days after the 5/10/26 change. Hospital documentation stated the resident had hematuria after the traumatic Foley exchange, was found to be in SVT, met sepsis criteria, had an ESBL UTI in the setting of the recent traumatic Foley insertion, and had two blood cultures positive for MRSA. Staff interviews confirmed the catheter was not changed timely and that the urology monthly order was not known at the time.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 543 citations issued within 25 miles in the last 12 months — including the 7 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 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 | ★★★★★ | 22 | 0 |
| Highland Park Rehabilitation & Care Center | 2.3 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.