Hill Top House

Inspectors wroteThe facility had a census of 21 residents. The sample included 12 residents and five nurse aides. Based on observation, record review, and interview, the facility failed to ensure three of the five staff members reviewed possessed the knowledge, skills, and competencies required for resident care needs. This placed the residents at risk of impaired care.

Inspectors wroteThe facility had a census of 21 residents. Based on record review and interview the facility failed to submit complete and accurate staffing information through Payroll Based Journal (PBJ) as required. This deficient practice placed the residents at risk for unidentified and ongoing inadequate nurse staffing.

Inspectors wroteThe facility had a census of 21 residents. Based on interviews and record review, the facility failed to implement a water management plan to mitigate risks for Legionella (a bacterium spread through the mist, such as from air-conditioning units for large buildings. Adults over the age of 50 and people with weak immune systems, chronic lung disease, or heavy tobacco use are most at risk of developing pneumonia caused by Legionella). The facility failed to maintain an antibiotic tracking system and did not review its infection control policies annually. This deficient practice placed the 21 residents of the facility at risk for infection.

Inspectors wroteThe facility had a census of 21 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to develop a baseline care plan within 48 hours of admission for Resident (R) 123. This placed the resident at risk for impaired care due to unidentified or uncommunicated care needs.

Inspectors wroteThe facility had a census of 21 residents. The sample included 12 residents with five reviewed for unnecessary drugs. Based on observation, interview, and record review the facility failed to obtain a stop date from the physician for the use of as-needed (PRN) lorazepam (antianxiety medication) for Resident (R) 9. This placed the resident at risk for complications related to psychotropic (alters mood or thought) medications and unnecessary medication.

Inspectors wroteThe facility had a census of 21 residents. The sample included 12 residents with two reviewed for hospice services. Based on observation, interview, and record review the facility failed to ensure a communication process and collaboration between the hospice provider and the facility for Resident (R) 9 and R17 to coordinate hospice services provided including visit frequency and assessment, medications, and medical equipment. This placed the residents at risk of impaired end-of-life care.

Inspectors wrote- Observation on 02/14/23 at 09:12 AM revealed Licensed Nurse (LN) G, Certified Medication Aide (CMA) M and Certified Nursing Assistant (CNA) N in the resident's room to provide R 12 morning cares CMA M raised the head of the bed and CNA N assisted her to pivot transfer from the bed. The resident's brief was wet and removed and staff sat the resident on the bedside commode. LN G held the back of the commode. Observation of the commode revealed the leg to the back rest of the commode. LN G held the back so it did not wobble or collapse while the resident used it. The back bar of the commode also had an area of rust approximately 4 inches long across the bar. On 02/14/23 at 09:15 AM, LN G stated she noticed commode lacked a wingnut the day before. LN G stated she reported the broken commode to Maintenance Staff U. LN G was unaware how long it had been broken. [...]

Inspectors wroteThe facility reported a census of 24 residents with 12 sampled. Based on interview and record review, the facility failed to review and revise the care plans for one Resident (R)17, regarding new interventions to prevent falls.

Inspectors wroteThe facility reported a census of 26 residents. Based on interview and record review the facility failed to address staffing in the Facility Assessment to document resources required to provide necessary care to the residents in regard to staffing across all shifts. This failure had the ability to affect all resident care in the facility.

Inspectors wroteThe facility reported a census of 26 residents. Based on observation, interview, and record review, the facility failed to provide the residents with a way to file a grievances anonymously.

Inspectors wroteThe facility reported a census of 26 residents, with 12 sampled, including one for dignity. Based on observation, interview, and record review, the facility failed to provide quality dignified care for Resident (R) 25 by allowing his fingernails to be overgrown with a dark substance under them after he requested staff trim them.

Inspectors wroteThe facility reported a census of 26 residents, with 12 included in the sample, including one for respiratory care. Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for Resident (R) 12 which included oxygen use and care. Findings Include: - Review of R12's Electronic Health Record (EHR) dated 06/11/21 documented the following diagnoses: schizophrenia (a psychotic disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), chronic obstructive pulmonary disease (COPD, a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), COVID-19, shortness of breath (SOB), and localized edema (swelling resulting from an excessive accumulation of fluid in the body tissues). [...]

Inspectors wroteThe facility reported a census of 26 residents, with 12 sampled, including one for discharge to the community. Based on interview and record review, the facility failed to complete a discharge summary to include the recapitulation of Resident (R) 28's stay.

Inspectors wroteThe facility reported a census of 26 residents, with 12 sampled, including one for respiratory care. Based on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards of practice for Resident (R) 12. - Findings Include: Review of Resident (R) 12's Electronic Health Record (EHR) dated 06/11/21 documented the following diagnoses: Schizophrenia (a psychotic disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), Chronic Obstructive Pulmonary Disease (COPD) - (a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), COVID 19, shortness of breath (SOB), and localized edema (swelling resulting from an excessive accumulation of fluid in the body tissues). [...]

Inspectors wroteThe facility reported a census of 26 residents. Based on interview and record review, the facility failed to ensure the staff person designated as the Infection Preventionist (IP) who was responsible for the facility's Infection Prevention and Control Program (IPCP) completed the specialized training in infection prevention and control.