Hilltop Healthcare Rehabilitation And Skilled Nurs
HILLTOP HEALTHCARE REHABILITATION AND SKILLED NURS in DULUTH, MN — inspection on March 12, 2026.
Found 10 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.
Inspection Findings
During an interview on 3/12/26 at 12:11 p.m., RN-E, a nurse manager, would expect an order to be discontinued after 14 days if that is what the order was for, and stated she wasn't sure what happened. RN-E stated her expectation was for behavior charting to be done every shift and when using a PRN AP medication.
During an interview on 3/12/26 at 2:59 p.m., pharmacy consultant (PC)-G would have expected the order to stop after 14 days, and for the provider to see the resident face to face if renewing an as-needed antipsychotic. A policy, Unnecessary Drugs-Psychotropic Drugs dated 2/27/23, identified residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. PRN orders for psychotropic medications will be limited to 14 days unless the physician identifies the rationale to extend the medication beyond 14 days. PRN antipsychotic drugs will be limited to 14 days and will not be renewed unless the physician evaluates the resident for appropriateness of the medication.
The provider should determine and document the following:Is the antipsychotic medication still needed on a PRN basis?What is the benefit of the medication to the resident?Have the resident's expressions or indications of distress improved as a result of the PRN medication?
245366 03/12/2026
Hilltop Healthcare Rehabilitation and Skilled Nurs 2501 Rice Lake Road Duluth, MN 55811
During an interview on 3/12/26 at 11:36 p.m., the director of nursing (DON) verified that a thorough investigation of R106's fall had not been documented.
The DON stated there was not any education completed for staff on falls, smoking, or smoking during inclement weather.
The DON stated it was important to complete a root cause analysis to figure out why the incident occurred, and to prevent reoccurrence.
The facility's root cause analysis of the incident was requested but not provided.
Incident Investigation Procedure dated 2/8/24, identified, All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator.
The policy identified any corrective action would be documented and other pertinent data as necessary or required.
The policy further identified, Incident/accident reports will be reviewed by the safety committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities.
245366 03/12/2026
Hilltop Healthcare Rehabilitation and Skilled Nurs 2501 Rice Lake Road Duluth, MN 55811
During an interview on 3/11/26 at 1:04 p.m., the director of nursing (DON) demonstrated the template used in the electronic medical record (EMR) when residents were transferred out of the facility indicating if they wanted a bed hold or not.
The DON added they had just changed to this process, but they did go over bed hold information with residents on admit and annually. A policy, Bed Holds dated 9/8/24, identified the resident or responsible party must be notified concerning the bed hold policy of Hilltop Healthcare and sign the policy as evidence that they have been properly notified prior to being charged for any service. A copy of this policy will be sent with the resident when transferred to the hospital. At the time of transfer or therapeutic leave, staff will provide the current resident/responsible party with a copy of the policy. In case of emergency transfer, staff will attempt to provide the resident with a copy and will notify the responsible party of the transfer and policy within twenty-four (24) hours.
Staff will follow up with a phone call to clarify any questions concerning the policy on the next working business day.
245366 03/12/2026
Hilltop Healthcare Rehabilitation and Skilled Nurs 2501 Rice Lake Road Duluth, MN 55811
reviewed, and revised by a team of health professionals.
interview and document review the facility failed to update a resident's care plan, including the
(R106) reviewed for accidents.Findings include:R106's quarterly Minimum Data Set, dated [DATE], identified R106 had diagnoses which included disease of spinal cord, dementia, diabetes mellitus, paranoid schizophrenia, insomnia, nicotine dependence, tobacco use, and repeated falls. In addition, R106's MDS identified he was moderately cognitively intact.R106's current care plan report identified he was at risk for falls.
Interventions included the following:Call light positioned for easy access initiated on 4/10/25Fall Review per facility protocol initiated on 4/10/25Have commonly used articles within easy reach initiated on 4/10/25Wheelchair-anti-rollbacks initiated on 5/19/25Call don't fall sign placed initiated on 5/19/25R106's care plan report identified R106 smoked.
Interventions included the following:Assess for safe smoking practice upon admission, quarterly, and as needed initiated on 4/10/25Educate/remind of the facility smoking policy as needed.
Has agreed to follow the policy initiated on 4/10/25Smoking material will be stored in locked drawer in room or designated safe area for example on person or in a pocket initiated on 4/10/25The facility smoking list provided on 3/9/26, listed R106 as a current smoker.The facility's investigation of R106's fall on 1/26/26, identified the following:The date the incident occurred, the location, R106's description of the incident (he was unable), immediate actions taken (lifted off of the ground with an assist of two, brought inside, nasal bleeding stopped, sent to the emergency department for evaluation).
The explanation was Fell off his w/c (wheelchair) outside in the smoking area.
Unable to explain incident. No statements gathered, no further notes on follow-up, no root cause analysis, no changes made to R106's care plan.
During an interview on 3/11/26 at 2:36 p.m., registered nurse (RN)-D recalled the incident when R106 fell. RN-D was unsure if R106's care plan had been updated but did state his power of attorney no longer wanted R106 to smoke, RN-D reviewed the care plan and verified it had not been updated.
During an interview on 3/12/26 at 11:36 a.m., the director of nursing (DON) verified there were no updates made to the resident's care plan after the incident.Incident Investigation Procedure dated 2/8/24, identified, All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator.
The policy identified any corrective action would be documented and other pertinent data as necessary or required.
The policy further identified, Incident/accident reports will be reviewed by the safety committee for trends related to accident or safety hazards in the facility and to analyze any individual resident vulnerabilities.
245366 03/12/2026
Hilltop Healthcare Rehabilitation and Skilled Nurs 2501 Rice Lake Road Duluth, MN 55811
parameters for significant weight loss was more than 2 pounds overnight or 5 pounds in a week.
With
R119's admission weight was 352.8.The facility document Standing Orders for Skilled Nursing
with heart failure unless otherwise directed.
245366 03/12/2026
Hilltop Healthcare Rehabilitation and Skilled Nurs 2501 Rice Lake Road Duluth, MN 55811
During an observation on 3/11/26 at 8:28 a.m., room trays were being passed to residents who were eating in their rooms. R99 received her breakfast in her bed.-at 8:34 a.m., R99 was seated in her bed.
The bed was elevated to about 45 degrees as she was eating her breakfast.-at 8:49 a.m., R99 remained in bed.
Both hands were under the covers; she was still at about 45 degrees her tray remained on the overbed table in front of her.-at 1:22 p.m., R99 was observed in bed eating lunch.
Her bed was at about 45 degrees.
During an interview on 3/11/26 at 1:24 p.m., registered nurse (RN)-B looked in R99's room and verified the bed was elevated at about 45 degrees. RN-B stated the bed should be at 90 degrees when R99 declined to get out of bed and come to the dining room for her meals. RN-B stated the head of the bed at 90 degrees was important to prevent choking.A policy on dysphagia was requested but not provided.
245366 03/12/2026
Hilltop Healthcare Rehabilitation and Skilled Nurs 2501 Rice Lake Road Duluth, MN 55811
minimal harm staffing information included the required information and was posted on the weekend.
This had the potential to affect all 103 residents, families and visitors who would wish to review the
posted in the main hallway where visitors entered.
The posting was dated 3/6/26, it had the name of the facility at the top of the page, the date and the day of the week, the census, the nursing hours and the hours per patient day.
Below these were listed the roles starting with the certified nursing assistant listed as 25 with a total of 189.5 hours.
Licensed practical nurses were listed as four with a total of 29.5 hours.
Registered nurses were listed as 10 with a total of 84 hours.
The posting dated 3/6/26 was for Friday in addition, the posting lacked nurse staffing separated out by shifts and did not include any information on trained medication aides.
During an interview on 3/12/26, staffing coordinator (SC)-D stated the nurse staffing was supposed to be posted daily which would include weekends. SC-D also verified the posting was supposed to include the staff working by shift and not just a total of all hours worked in a 24-hour period.
During an interview on 3/12/26 at 12:16 p.m., the director on nursing (DON) stated the staff posting was supposed to be posted for families and residents so they would be able to see how many staff were working on each shift.The Daily Staff Posting dated 10/17/25, identified the posting would include the following information: Content Requirement: Posting must include the number of nursing staff (RN, LPN, TMA, CAN) on duty per shift.
Must list the total number and actual hours worked along with the current resident census.
The title identified the posting would be posted daily.
recommendation and subsequent provider order to help prevent unnecessary medication use for 1 of 5
set (MDS) dated [DATE], identified intact cognition and diagnoses of congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), diabetes mellitus, and hypertension.R83's provider orders dated 3/25/25, identified acidophilus (a supplement with beneficial bacterium) two times per day for prevention of urinary tract infections (UTI).A document, Physician/Provider Recommendation dated 9/12/25, identified a pharmacist recommendation to consider a trial discontinuation of acidophilus to help prevent polypharmacy, excessive pill burden, and unnecessary medication.
The provider responded on 10/3/25 to discontinue lactobacillus (acidophilus) due to therapy completed.
During an interview on 3/12/26 at 12:02 p.m., registered nurse (RN)-E, a nurse manager, stated the pharmacy recommendations went to the providers as soon as they got to the nurse managers. RN-E added she wasn't sure what happened with this one, her expectation would be that all orders were acted on.
During an interview on 3/12/26 at 2:52 p.m., the pharmacist consultant (PC)-G stated she would expect follow up on pharmacy recommendations within 30 days. A policy regarding unnecessary medications, non-psychotropic, was not received.
245366 03/12/2026
Hilltop Healthcare Rehabilitation and Skilled Nurs 2501 Rice Lake Road Duluth, MN 55811
During an interview on 3/12/26 at 10:42 am the administrator and
meals.
Anything beyond one hour from start of mealtimes is not acceptable.On 3/12/26 at 11:48 a.m., an announcement was again made that the lunch service on that day would start 30 minutes late.The dining hall and service line policy was requested but not provided.
245366 03/12/2026
Hilltop Healthcare Rehabilitation and Skilled Nurs 2501 Rice Lake Road Duluth, MN 55811
During plating of food she went to fridge, opened fridge, grabbed another metal container and placed it in the steam table with the same gloved hands.
She then continued to plate food touching the bread of each sandwich with the same gloved hands and placing them on plates.During interview on 03/10/2026 at 7:26 p.m., C-A stated, that is my bad. I should have taken off my gloves, went out there, sanitized my hands, and put on new gloves prior to plating food.During interview on 03/12/2026 at 10:38 a.m., the director of nursing (DON) stated that her expectation would be that the staff would have removed the gloves, completed hand hygiene, and donned new gloves prior to plating food.
245366 03/12/2026
Hilltop Healthcare Rehabilitation and Skilled Nurs 2501 Rice Lake Road Duluth, MN 55811