Hilltop Village Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Hilltop Village Nursing and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678May 27, 2023

  Based on observation, interview and record review the facility failed to follow physician orders and the resident's advance directives for 1 of 24 Residents (Resident #76) whose records were reviewed for DNR code status. The facility failed to ensure nursing staff followed emergency protocol and failed to ensure staff did not provide Resident #76, who had a DNR in place, CPR, after the resident choked and became unresponsive, according to professional standards of practice. An Immediate Jeopardy (IJ) situation was identified on [DATE]. […]

• No harm, potential for more than minimal, widespreadF812May 27, 2023

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen for review: 1. DA L had facial hair and was not wearing a facial hair restraint while engaged in food preparation. 2. There were frozen omelets, pizza crusts, pie crusts and garlic bread that were improperly stored in the reach-in freezers. 3. There was an opened carton of thickened orange juice and an opened carton of thickened sweet tea without labels indicating the dates they were opened. 4. There was a case of frozen fish fillets and a case of frozen carrots that were improperly stored in the walk-in freezer. 5. […]

• No harm, potential for more than minimal, widespreadF812Mar 25, 2022

  Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: Cook B was preparing food in the kitchen and did not have a facial hair restraint covering his facial hair. This deficient practice could place residents who received meals and/or snacks from the kitchens at risk for food borne illness. The findings were: Observation on 03/24/22 at 10:45 a.m. revealed Cook B had his face mask below his chin. He had a moustache that extended the length of his mouth and a beard that covered his chin and extended the length of his jawline, and he was not wearing a facial hair restraint. […]

• No harm, potential for more than minimal, widespreadF835Mar 25, 2022

  Based on interviews and record reviews, the facility failed to provide the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 11 out of 24 total residents (Residents #77, #26, #41, #33, #2, #22, #32, #27, #59, #15, and #35) whose care was reviewed for administration, in that: 1. Resident #77 received 8 showers out of 10 opportunities in a 22-day period. 2. Resident #26 received 3 showers out of 12 opportunities in a 30-day period. 3. Resident #41 received 1 shower out of 13 opportunities in a 30-day period. 4. Resident #33 received 3 showers out of 13 opportunities in a 30-day period. 5. Resident #2 received 2 showers out of 13 opportunities in a 30-day period. 6. Resident #22 received 6 showers out of 13 opportunities in a 30-day period. 7. […]

• No harm, potential for more than minimal, patternF756Aug 27, 2025

  Based on observation, interview, and record review, the facility failed to ensure medication irregularities reported from the pharmacist were reported to the attending physician and the facility's medical director and director of nursing, and these reports were acted upon for 1 of 4 residents (Resident #4) reviewed for medications. The facility failed to ensure an order discrepancy for Resident #4's medication Pramipexole (a medication for a progressive neurological disorder known as Parkinson's Disease) identified by a report from the pharmacist to the facility on 6/23/2025 was resolved causing Resident #4 to receive dosing of the medication greater than intended for June, July, and August of 2025. […]