The Hills Nursing & Rehabilitation

In the surveyor’s words

From the most serious findings on record at The Hills Nursing & Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, patternF689Apr 30, 2025

  Based on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 of 3 residents (Residents #1 and #2) reviewed for accidents. 1. Driver A failed to secure Resident#1's wheelchair properly in the van, resulting in the resident hitting her head when the wheelchair tipped backwards during transport on 03/18/25. The resident was sent to the hospital but did not have any injuries. 2. Driver B failed to secure the safety strap on the lift when Resident #2 was being lowered. Driver B fell on to Resident #2 causing him to tip backwards in his wheelchair and hitting his head on the ground on 04/07/25. […]

• Immediate jeopardy, patternF656Mar 14, 2025

  Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs for 1 of 10 residents (Resident #1) reviewed for care plans. The facility failed to develop and implement a care plan for Resident #1 to address him being at risk for constipation which he was at increased risk for due to his diagnosis of cerebral palsy. […]

• Immediate jeopardy, patternF684Mar 14, 2025

  Based on interviews and record reviews, the facility failed to ensure that received residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices based on the comprehensive assessment of a resident for 1 of 10 residents (Resident #1) reviewed for quality of care. The facility failed ensure Resident #1, who was at increased risk for constipation due to having cerebral palsy, had measures in place to monitor his bowel activity and to ensure physician ordered interventions were implemented when the resident did not have a bowel movement within 72 hours. […]

• Immediate jeopardy, patternF760Mar 14, 2025

  Based on interviews and record reviews, the facility failed to ensure that residents are free of any significant medication errors for 1 of 10 residents (Resident #1) reviewed for medications. The facility failed ensure Resident #1, who was at increased risk for constipation due to having cerebral palsy, was administered his physician-ordered Bisacodyl Rectal Suppository when he had only one bowel movement between 02/11/25 and 02/26/25. This failure resulted in the resident being diagnosed in the hospital with fecal impaction of the rectum with associated stercoral colitis, which is a rare inflammatory colitis that occurs when impacted fecal material leads to distention of the colon and eventually hardened stool formation. […]

• Immediate jeopardy, isolatedF580Jul 23, 2026

  Based on interview and record review the facility failed to immediately inform the resident, consult with the resident's physician and notify, consistent with his or her authority, the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status in either life-threatening conditions or clinical complications for 1 of 5 residents (Resident #1) reviewed for change of condition. The facility staff failed to notify the NP or Physician when Resident #1 began to have a change of condition on [DATE] when he experienced lethargy, clammy skin, was unable to verbally talk to staff, and did not appear to be himself. Resident #1 continued to have a change of condition until [DATE] when he was sent to the hospital and passed away. […]