Hill View Skilled Nursing and Rehabilitation Cente

In the surveyor’s words

From the most serious findings on record at Hill View Skilled Nursing and Rehabilitation Cente, in the surveyor’s own words.

• Actual harm, isolatedF686Jun 10, 2026

  Based on record review, observation, staff interview, and policy review, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to prevent the development of avoidable pressure ulcers, failed to thoroughly assess a resident's skin, and failed to timely identify pressure ulcers until they had reached an advanced stage. Actual Harm occurred on 10/13/25 when Resident #61, who was cognitively impaired and dependent on staff for bed mobility, developed an unstageable pressure ulcer to the left heel (a full thickness wound where damage depth is hidden by slough or eschar making an accurate stage assessment impossible.) This affected one (Resident #61) of two residents reviewed for pressure ulcers. The facility census was 69. […]

• Actual harm, isolatedF697Dec 10, 2025

  Based on medical record review, staff interview, review of the facility's fall investigation, review of the hospital notes, review of the Medscape guidance, and review of the facility's pain management policy, the facility failed to provide adequate pain management for one resident. This result in Actual Harm for Resident #64 who screamed out in pain at multiple staff, receiving a delay and appropriate treatment of pain beginning 10/30/25 at 6:30 P.M. to 10/31/25 at 12:40 A.M. This resulted in an emergency room visit for acute pain and reporting a severe pain level of nine (pain scale from zero indicating no pain to ten being worst pain). This affected one (Resident #64) of three residents reviewed for pain control. […]

• No harm, potential for more than minimal, widespreadF812Jun 10, 2026

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

• No harm, potential for more than minimal, widespreadF814Jun 10, 2026

  Based on observation and staff interview, the facility failed to ensure all kitchen garbage receptacles including outdoor dumpsters were equipped with proper fitting lids to deter animals and pests. This had the potential to affect all of the residents residing in the facility. The facility census was 69 residents. Findings include: Observations on 06/01/26 at 10:20 A.M. and at 2:20 P.M. revealed there were two outside dumpsters near the loading dock which were not covered with lids. Observation on 06/02/26 at 10:51 A.M. with the Administrator revealed the outside dumpsters near the loading dock were not covered with lids. Interview on 06/02/26 at 10:51 A.M. with the Administrator verified the dumpsters did not have lids. […]

• No harm, potential for more than minimal, widespreadF921Aug 8, 2025

  Based on observation, staff interview, and review of the facility policy, the facility failed to ensure the environment was maintained in good repair. This had the potential to effect all residents residing in the facility. The facility census was 64.Findings include:Observations on 08/08/25 from 10:22 A.M. through 11:30 A.M., during a tour of the facility, revealed a large portion of the ceiling in the second-floor dining room was missing. The area below the missing ceiling had yellow caution tape set up to keep people from walking underneath it. Continued observation of the second-floor hallway, outside of Resident #2's room, revealed discolored ceiling tiles and water was leaking down into a large and a small trash can placed underneath. […]