Hilltop Nursing & Rehabilitation Center
Inspection Findings
F-Tag F0600
F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
will be completed by 08/28/2025. The in-service covers the following:-The requirements to notify the MD of each and every fall, regardless of injury. This notification should be documented in the medical record.-The requirements to document each and every fall in the medical record. The documentation should include a description of the incident and assessment of the resident.-The importance of promptly sending the resident to the emergency room, when indicated based on the assessment, or as ordered by the MD.-The importance of assessing for pain with falls and administering prn pain medication, if ordered and indicated.-Nurses were reminded to always notify the DON or ADON with any questions or concerns. They were also instructed to immediately notify the DON or ADON with any injury requiring and emergency room visit.To ensure understanding of the in-service, a post-test has been developed for each nurse to complete following the in-service. This post-test also contains questions related to documentation of falls in the medical record, notification of MD of regarding falls and sending residents to the ER immediately, if indicated. The post-test also addresses administration of prn medications, if indicated.Additional in-services will be initiated for all nurses by the DON and/or ADON beginning on 08/28/2025. This in-service will address the following:-The definition of neglect-examples of neglect will be reviewed, which will include the following, at a minimum; Failing to notify the MD of a fall with injury, failing to document a fall, failing to document as assessment following a fall, and failing to promptly send the resident to the ER.Nurses will not be allowed to work until they have been in-serviced. Monitoring of Implemented Actions:To ensure residents are promptly cared for following a fall and no neglect has occurred, a QAPI Monitor had been implemented and will begin on 08/28/2025 to ensure the MD was notified, an assessment was documented, the resident was sent to the ER in a timely manner, if ordered or required, and pain medication was administered, if ordered and indicated. This monitor will be completed by the DON or designee on each fall that occurs 3 times a week for 6 weeks, and then monthly thereafter until compliance is reached.To ensure residents are promptly cared for, falls are addressed and no neglect has occurred, and additional QAPI Monitor has been created. The DON or designee will randomly interview 5 CNA's and 3 nurses, questioning their knowledge of any recent falls. If the staff member recalls a fall, this information will be reconciled with the medical
record for compliance. This monitor will be completed 3 x week for 6 weeks, and then monthly thereafter until compliance is reached.To ensure continued understanding of the in-service related to neglect, the DON or designee will interview a random sample of at least 3 nurses 3 x a week for 6 weeks, and them monthly thereafter until compliance is reached. This interview will contain questions related to neglect, notification of MD with falls, documentation of falls in the medical record, documentation of assessments related to falls and sending a resident to the ER promptly when ordered or as required.The effectiveness of
the corrective actions will be discussed weekly for 6 weeks at the Quality Assurance and Performances Improvement Meeting with findings added to the QAPI minutes. Additional in-services and/or corrective actions will be implemented as needed.
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
08/28/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hilltop Nursing & Rehabilitation Center
336 Edgewood Drive Pineville, LA 71360
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0658
F 0658 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
DON or ADON with any injury requiring and emergency room visit.To ensure understanding of the in-service, a post-test has been developed for each nurse to complete following the in-service. This post-test also contains questions related to documentation of falls in the medical record, notification of MD of regarding falls and sending residents to the ER immediately, if indicated. The post-test also addresses administration of prn medications, if indicated.Additional in-services will be initiated for all nurses by the DON and/or ADON beginning on 08/28/2025. This in-service will address professional standards of practice related to the following: -It is professional standards of practice to notify the MD of falls-It is professional standards of practice, following a fall, to administer pain medications when a resident is in pain and has pain medication ordered. If no pain medication is ordered, the MD should be notified so orders can be obtained. -It is professional standard of practice to promptly send a resident to the ER when ordered or required based on assessment. -Resident Rights will be reviewed with each nurse as well. Nurses will not be allowed to work until they have been in-serviced. Monitoring of Implemented Actions: A QAPI Monitor had been implemented and will begin on 08/28/2025 to ensure Professional Standards are maintained following a fall, by ensuring the MD was notified, an assessment was documented, the resident was sent to
the ER in a timely manner, if ordered or required, and pain medication was administered, if ordered and indicated. This monitor will be completed by the DON or designee on each fall that occurs 3 times a week for 6 weeks, and then monthly thereafter until compliance is reached.An additional QAPI Monitor has been created to ensure Professional Standards are maintained following a fall by ensuring that falls have been addressed in the medical record. The DON or designee will randomly interview 5 CNA's and 3 nurses, questioning their knowledge of any recent falls. If the staff member recalls a fall, this information will be reconciled with the medical record for compliance. This monitor will be completed 3 x week for 6 weeks, and then monthly thereafter until compliance is reached.To ensure continued understanding of the in-service related to Professional Standards, the DON or designee will interview a random sample of at least 3 nurse, 3 x a week for 6 weeks, and then monthly thereafter until compliance is reached. This
interview will contain questions related to Professional Standards, notification of MD with falls, assessing residents with falls, administering pain medications if needed and available and promptly sending residents to the ER when ordered or required.To further ensure Professional Standards are maintained, the DON or ADON will complete Performance Evaluations on 4 nurses weekly for 6 weeks, and then monthly thereafter until compliance is reached. The Corporate nurse will oversee the plan of removal and plan of correction and will also ensure that follow-up regarding the specific areas will be conducted. The effectiveness of the corrective actions will be discussed weekly for 6 weeks at the Quality Assurance and Performances Improvement Meeting with findings added to the QAPI minutes. Additional in-services and/or corrective actions will be implemented as needed.
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
08/28/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hilltop Nursing & Rehabilitation Center
336 Edgewood Drive Pineville, LA 71360
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0732
F 0732
Post nurse staffing information every day.
Level of Harm - Minimal harm or potential for actual harm
Based on observation and interview the facility failed to ensure that the nurse staffing pattern was posted daily. The facility census was 89.Findings: Observation on 08/25/2025 at 11:00 a.m. of the posted facility staffing pattern revealed a date of 08/13/2025. Observation and interview on 08/25/2025 at 2:35 p.m. with S2 DON and S10 RN/Charge Nurse stated the [NAME] Clerk had quit abruptly and she was responsible for
the daily posting of the facility's staffing pattern. S2 DON confirmed the posted facility staffing sheet was dated 08/13/2025 and did not reflect the current date or staffing, and it should.
Residents Affected - Many
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Hilltop Nursing & Rehabilitation Center in Pineville, LA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
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 Pineville, LA, (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 Nursing & Rehabilitation Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.