Lutheran Hillside Village

In the surveyor’s words

From the most serious findings on record at Lutheran Hillside Village, in the surveyor’s own words.

• Actual harm, isolatedF689Jun 17, 2026

  Based on interview, observation and record review, the facility failed to provide appropriate nursing interventions related to life-sustaining treatment during a choking episode, failed to provide supervision during meals and failed to follow a physician's diet order; and failed to obtain a Negotiated Risk Assessment for one of three (R1) residents reviewed with swallowing difficulty and on special/modified diets who required supervision during meals. This failure resulted in R1 choking on a tater tot and ultimately expired. This past non-compliance, which involved R1, occurred from 4/15/26 to 5/12/26.Findings include:The Emergency Response policy revised 10/23/24 documents the goal of staff training is to enable employees to provide basic life support and/or first aid interventions. […]

• Actual harm, isolatedF689Nov 16, 2022

  Based on observation, interview and record review, the facility failed to properly secure and use the correct sling during a mechanical transfer for one (R1) of three residents reviewed for mechanical transfers in a sample of four. These failures resulted in (R1) slipping through the slit/hole in the back of the sling and suffering a left [CONDITION(S)]. Findings include: Facility Event Reporting, revised 7-29-2021, documents Events involving a resident, visitor, or other person (non-employee) that are outside of usual or normal happenings and present a potential liability, and events that are not in keeping with standards, policies, procedures or practices and may have an adverse outcome will be documented. […]

• Actual harm, isolatedF760Feb 23, 2022

  Based on interview and record review the facility failed to ensure a resident's physician ordered antihypertensive medication was correctly transcribed and ordered for one of three residents (R1) reviewed for medications in the sample of three. This failure resulted in R1 receiving triple the dose of an antihypertensive medication at three different times. R1 became dizzy and hypotensive with altered level of consciousness. R1 required emergent transfer via ambulance to the local area hospital in which R1 received five doses of a reversal agent intravenously and was admitted to the Intensive Care Unit on blood pressure support medication. Findings include: The facility's Receiving and Transcribing Orders Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF577Dec 13, 2024

  Based on observation, interview and record review the facility failed to place the facility's annual State Survey Results in a readily accessible location for residents for viewing. This failure has the potential to affect all 69 Residents residing at the facility. Findings include: The facility's Resident Rights Policy, dated 1/30/24 document: Policy Statement: Staff shall treat all residents with kindness, respect, and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of the (facility) community. These rights include the resident's right to: H. Be supported by the (facility) community in exercising their rights; M. Exercise rights not delegated to a legal representative; and W. […]

• No harm, potential for more than minimal, patternF758Jan 26, 2023

  Based on observation, interview and record review, the facility failed to monitor for identified target behaviors and failed to ensure that identified target behaviors were an indication for the use of an antipsychotic medication for seven of seven residents (R3, R17, R23, R34, R35, R50, and R119) reviewed for psychotropic medications in a sample of 32. Findings include: The facility's Psychotropic Medication Policy, revision date 2/14/20, documents, Residents will not receive psychotropic medications unless behavioral programming and/or environmental changes or other non-pharmacological interventions have failed to sufficiently address the resident's target behavioral goals. […]