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Complaint Investigation

Hilltop Park Post Acute

July 29, 2024 · Denver, CO · 290 S Monaco Pkwy
Citations 4
CMS Rating 2/5
Beds 160
Provider ID 065241
Healthcare Facility
Hilltop Park Post Acute
Denver, CO  ·  View full profile →
Inspection Summary

HILLTOP PARK POST ACUTE in DENVER, CO — inspection on July 29, 2024.

Found 4 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF622
Minimal harm or Few Based on record review and interviews, the facility failed to provide evidence that a quarterly statement was affected

According to the July 2024 computerized physician's orders (CPO), diagnoses included dementia.

The 7/17/24 MDS assessment revealed the resident had severely impaired cognition with a BIMS score of four out of 15.

065241

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 065241 B.

Wing 07/29/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hilltop Park Post Acute 290 S Monaco Pkwy Denver, CO 80224

According to the April 2024 CPO, diagnoses included calculus of bile duct with cholecystitis, post traumatic stress disorder, borderline personality disorder and need for assistance with personal care.

The 3/25/24 MDS assessment documented the resident was cognitively intact with a BIMS score of 14 out of 15. He required setup assistance with activities of daily living (ADL).

B.

Record review

065241

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 065241 B.

Wing 07/29/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hilltop Park Post Acute 290 S Monaco Pkwy Denver, CO 80224

F-F686 Pressure injuries:

The facility failed to implement interventions and treatment to prevent a resident from developing a facility-acquired unstageable pressure injury that evolved into a stage 4 pressure injury which became infected.

III.

Interviews

065241

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 065241 B.

Wing 07/29/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hilltop Park Post Acute 290 S Monaco Pkwy Denver, CO 80224

F-F867 for failure to ensure QAPI improvement activities.

-The records of the five randomly selected CNAs (#3, #4, #5, #6 and #7) were reviewed and none of the CNAs received all of the required training sessions (all required components of abuse training, QAPI, Compliance and ethics and resident rights) and none had received a total of 12 hours of annual in-service training.

-The training records failed to document the training sessions' durations.

III.

Staff interviews

The NHA was interviewed on 7/29/24 at 2:22 p.m.

The NHA said the facility had not provided any staff training on the QAPI program but they would get started on planning for the training.

The NHA said they had trained all staff on abuse.

-However, the abuse training topic was on the topic of elder and dependent adult abuse reporting and not abuse prevention and identification.

-Additionally, some staff received the training more than 12 months prior to the survey and had no record of being provided a refresher training on an annual basis

The NHA was interviewed again on 7/31/24 in a follow-up regarding the CNA training records.

The NHA said the annual CNA training was a bit bare and the facility would be working on getting the CNAs training up-to-date, along with the QAPI training.

.

065241

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in DENVER, CO, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from HILLTOP PARK POST ACUTE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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