Hillspring Health Care & Rehab

In the surveyor’s words

From the most serious findings on record at Hillspring Health Care & Rehab, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF686Aug 20, 2026

  Based on medical record review, staff interview, wound nurse practitioner interview, policy review, and review of the National Pressure Injury Advisory Panel (NPIAP) guidelines, the facility failed timely identify a deep tissue injury (DTI) (a serious type of pressure injury where the soft tissue beneath the skin is damaged by prolonged pressure or friction) and timely refer to the wound nurse practitioner for a resident identified with a deep tissue injury. This affected one (Resident #03) out of four Residents (#03,#12, #63, #119) reviewed for pressure wounds. The facility census was 128.Findings include:Review of the medical record for Resident #03 revealed an admission date of 11/19/25. […]

• No harm, potential for more than minimal, isolatedF558Jun 17, 2026

  Based on interview, record review and policy review, the facility failed to ensure staff allowed a resident to have her personal cell phone. This affected one (Resident #2) of three residents reviewed for personal property. The facility census was 127.Findings include:Review of the medical record revealed Resident #2 was admitted to the facility on [DATE]. Diagnoses included chronic diastolic heart failure, chronic kidney disease, stage three, dementia, anxiety disorder, history of falling, and mild cognitive impairment.Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #2 had moderately impaired cognition, and required set up assistance from staff with eating and personal hygiene. […]

• No harm, potential for more than minimal, isolatedF583Jun 17, 2026

  Based on observation, interview, record review and policy review, the facility failed to ensure the resident's privacy was maintained during personal care. This affected one (Resident #43) of three residents reviewed for privacy. The facility census was 127.Findings include:Review of the medical record revealed Resident #43 was admitted to the facility on [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebrovascular disease, vascular dementia, anxiety disorder and major depressive disorder.Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #43 was cognitively intact and dependent on staff for toileting. Interview and observation on 06/16/26 at 2:05 P.M. to 2:20 P.M. […]

• No harm, potential for more than minimal, isolatedF609Jun 17, 2026

  Based on medical record review, review of the facilities Self-Reported Incidents (SRI), staff interview, and policy review, the facility failed to ensure all allegations of physical abuse were reported to the State Survey Agency. This affected one (#2) of one resident reviewed for abuse. Findings include: Review of the medical record revealed Resident #2 was admitted to the facility on [DATE]. Diagnoses included chronic diastolic heart failure, chronic kidney disease, stage three, dementia, anxiety disorder, history of falling, and mild cognitive impairment.Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #2 had moderately impaired cognition, dependent on staff with bathing and required set up assistance from staff with eating and personal hygiene. […]

• No harm, potential for more than minimal, isolatedF755May 28, 2025

  Based on medical record reviews, staff and resident interviews, review of a facility medication error report, and facility policy review, the facility failed to administer medications as ordered. This affected one( #15) resident out of three residents reviewed for medications administration. The facility census was 117. Findings include: Review of the medical record for Resident #15 revealed an admission date of 04/10/25 with medical diagnoses of pulmonary hypertension, disorder of the autonomic nervous system, left hemiplegia, and atrial fibrillation. […]