Inspection Reports for
Hilltop Park Post Acute

The complaint investigation found that the facility did not make prompt efforts to resolve food grievances, failed to fully investigate and document grievance resolutions, and did not take meaningful corrective actions. Resident interviews and record reviews revealed repeated issues with meal ticket inaccuracies and cold food, with seven grievances related to food and mealtimes from July to September 2025. The dietary manager and nursing staff acknowledged ongoing problems, and the director of nursing expressed disappointment in the facility's response to grievances.

The facility failed to ensure timely and effective responses to resident grievances concerning food quality and meal service. Multiple residents reported ongoing issues with cold food, inaccurate meal tickets, and poor communication from dietary staff, with inadequate investigation and corrective actions documented by the facility.

The complaint investigation focused on resident grievances about poor food quality, meal ticket inaccuracies, and cold food. The grievances were substantiated as the facility failed to resolve these issues or document corrective actions adequately.

The facility failed to respond adequately to resident grievances about food quality, meal ticket accuracy, and cold food complaints. Documentation and investigation of grievances were incomplete, and corrective actions were not effectively implemented.

The complaint investigation revealed multiple issues including resident rights violations, improper management of personal funds, inadequate discharge and transfer procedures, failure to prevent and treat pressure injuries, lack of nursing staff competency assessments, failure to provide necessary medical transportation, ineffective quality assurance program, and insufficient staff training.

The facility failed to ensure resident rights were respected, personal funds were properly managed, discharge and transfer processes were adequately documented and safe, pressure injuries were prevented and treated appropriately, nursing staff competencies were assessed and maintained, transportation needs were met, and staff received required training. Significant deficiencies included failure to provide timely pressure injury care resulting in a stage 4 pressure injury with osteomyelitis, failure to assist a resident with necessary gurney transportation, and incomplete discharge planning and summaries.

The complaint investigation focused on multiple areas including resident rights violations, improper management of personal funds, inadequate discharge planning and notification, failure to prevent and treat pressure injuries, lack of transportation assistance, and insufficient staff training and competency. Several residents were affected with substantiated findings.

The facility failed to ensure resident rights were respected, personal funds were properly managed, discharges were appropriately planned and documented, pressure injuries were prevented and treated properly, transportation needs were met, and staff received adequate training and competency assessments.

The investigation was complaint-driven, focusing on allegations of neglect, medication errors, respiratory care failures, infection control breaches, and improper medication storage.

The facility was found deficient in multiple areas including neglect of residents due to lack of supplies, improper medication administration practices, failure to provide timely insulin, inadequate respiratory care including lack of supplies and staff training, improper infection control practices, and medication storage issues.

The complaint investigation found substantiated neglect due to inadequate provision of necessary supplies, confirmed by resident interviews, staff interviews, and direct observations.

The facility failed to ensure seven of 10 sampled residents were kept free from neglect by not providing essential supplies needed for their care, including adult briefs, wipes, linens, towels, and washcloths. Observations and interviews confirmed frequent shortages of these supplies, impacting residents' hygiene and well-being.

The facility was found deficient in multiple areas including failure to provide adequate supplies to residents, improper medication administration practices, delayed insulin administration, failure to assist with vision devices, inadequate feeding tube care, unsafe respiratory care practices creating immediate jeopardy, improper medication cart storage, and failure to follow infection control PPE protocols.

The complaint investigation found substantiated neglect related to inadequate provision of supplies necessary for resident care, including adult briefs, wipes, linens, towels, and washcloths. Multiple residents and staff interviews confirmed frequent shortages and difficulties accessing supplies.

The facility failed to ensure seven of ten sampled residents were kept free from neglect by not providing adequate supplies needed for their care. Observations and interviews confirmed frequent shortages of adult briefs, wipes, linens, towels, and washcloths, impacting resident hygiene and well-being.

The complaint investigation found that Resident #3 remained in the facility beyond the 30-day provisional admission period without a new PASRR Level I screening being submitted. The complaint was substantiated based on record review and interviews.

The facility failed to submit a new PASRR Level I screening for Resident #3 after the 30-day provisional admission period expired. Interviews confirmed the social service director was unfamiliar with the provisional admission process and the PASRR program administrator stated the facility did not submit the required screening.

The facility failed to submit a new PASRR Level I screening for Resident #3 after the 30-day provisional admission period expired. Interviews and record reviews confirmed that the facility did not comply with the PASRR screening requirements for this resident.

The facility failed to implement proper policies and procedures related to pneumococcal immunizations for six of eight residents reviewed. Issues included failure to offer vaccines upon admission, failure to offer additional doses, and lack of signed consent for refusals.

The facility failed to implement proper policies and procedures regarding pneumococcal vaccinations for six of eight residents reviewed. Specific failures included not offering the vaccine upon admission, not offering additional doses, and lacking signed consent for refusals. The facility's documentation and use of the Colorado Immunization Information System (CIIS) were inconsistent.

The complaint investigation found that medical records for Residents #1 and #6 were not provided timely. Additionally, Residents #1, #2, and #3 were not assessed by a registered nurse following falls, which is required. The nursing home administrator and director of nursing acknowledged these failures during interviews.

The facility failed to provide requested medical records timely for two residents and failed to ensure registered nurse assessments were completed following falls for three residents. These deficiencies were supported by record reviews and staff interviews.

The complaint investigation found that medical records for Residents #1 and #6 were not provided timely despite multiple requests. Additionally, the facility failed to ensure RN assessments were completed and documented following falls for Residents #1, #2, and #3.

The facility failed to provide requested medical records timely for Residents #1 and #6, and failed to ensure that Residents #1, #2, and #3 were assessed by a registered nurse following falls, with documentation missing for RN assessments prior to residents being moved after falls.

The complaint investigation focused on failure to provide advance beneficiary notifications for Medicare Part A service terminations, failure to complete PASARR screenings timely, failure to develop appropriate care plans for wounds, failure to provide regular bathing and hygiene care, and failure to administer influenza vaccinations as requested.

The facility failed to provide timely ABNs and Notices of Medicare Non-Coverage (NOMNC) to residents discharged from Medicare Part A services, failed to complete level I PASARR screenings prior to admission for some residents, failed to develop a care plan for a resident's vascular wound, failed to provide regular bathing and hygiene care to a dependent resident, and failed to ensure influenza vaccination was administered to a resident who requested it.

The facility failed to provide advance beneficiary notices to residents discharged from Medicare Part A services, did not complete timely PASARR screenings for some residents, failed to develop a care plan for a resident's vascular wound, did not ensure regular bathing for a dependent resident, and failed to administer influenza vaccination to a resident as requested.

The facility was found deficient in multiple areas including failure to complete PASRR Level II screening prior to admission, inadequate treatment and services for activities of daily living, failure to prevent worsening of stage four pressure ulcers, inadequate supervision and fall prevention, failure to provide appropriate pain management, failure to collaborate effectively with hospice providers, and lapses in infection prevention and control practices.

The facility failed to provide PASRR Level II screening for a resident with mental illness prior to admission, did not follow physician orders for wound care and protective equipment, failed to update care plans and assess residents after falls, inadequately managed pain for residents with pressure ulcers, lacked proper collaboration and documentation with hospice providers, and failed to ensure proper infection control practices including hand hygiene and PPE use.