Hilltop Center

Inspectors wroteBased on record review, staff interview, resident interview, and observation, the facility failed to ensure physician orders were followed for residents receiving oxygen therapy. This failed practice had the potential to affect a limited number of residents. Resident Identifiers: #54 and #87. Facility Census: 117.

Inspectors wroteBased on observation, resident interview, and staff interview, the facility failed to provide adequate hydration for Residents #55, #107, and #68. These were random opportunities for discovery. Resident Identifiers: #55, #107 and #68. Facility Census: 117. Findings Included:a) Resident #55On 05/11/26 at 12:25 PM, an initial interview was held with Resident #55. The resident stated, I would like some ice water. The resident was asked, Did you get any fresh ice water today? Resident #55 stated, No, I haven't. An observation was made at this time of a 12-ounce Styrofoam cup, which was undated, that had a small amount of water and no ice inside the cup. On 05/11/26 at 12:30 PM, Activities Director #55 was asked to come into the resident's room. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to maintain an effective infection control program related to the placement of urinary catheter drainage bags for Resident #72 and #78, and storage of a granulated cylinder for Resident #54. These were random opportunities for discovery. Resident Identifiers: #72, #78 and #54. Facility Census: 117. Findings Included:a) Resident #72On 05/11/26 at 12:19 PM, an initial interview was held with Resident #72. The urinary catheter drainage bag was observed behind the wheelchair hanging and touching the floor. On 05/11/26 at 12:23 PM, the Activities Director #55 was asked to come to the resident's room. The Activities Director #55 confirmed the urinary catheter drainage bag should not be touching the floor. The Activities Director #55 raised the bag and the urinary catheter drainage bag was not touching the floor. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to ensure call systems were within the resident's reach. This failed practice had the potential to affect a limited number of residents. Resident Identifiers: #69 and #85. Facility Census: 117.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the resident's care plans were comprehensive, patent-centered and individualized for transfers. This was found true for five(5) of 31 care plans reviewed during the Long Term Care Survey process. Resident Identifiers: #2, #9, #84, #85, and #105. Facility Census: 117.

Inspectors wroteBased on record review, observation, staff interview and resident interview, the facility failed to ensure a resident's call light was adapted to a resident's individual physical needs. This failed practice was a random opportunity for discovery and had the potential to affect a limited number of residents. Resident identifier: #84. Facility census: 117.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a comprehensive assessment of resident preferences for customary routine and activities was completed and documented in the annual Minimum Data Set (MDS) for one (1) of two (2) residents. This was true for Resident #15. Resident identifier: #15. Facility census: 117.

Inspectors wroteBased upon record review and staff interview, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program when a new mental health diagnosis or change in condition is presented. This was found to be true for one (1) of six (6) residents during the long term care survey process. Resident identifier #87. Facility census: 117. Resident #87 a) On 01/20/26 reviewed Resident #87 PASARR dated 09/17/24. It was observed that the only diagnosis on the form was Delusional Disorder. According to the medical diagnosis listed for Resident #87 was diagnosed with conversion disorder with seizures or convulsions and anxiety disorder unspecified on 02/05/25. [...]

Inspectors wroteBased on record review , observation, staff interview and resident interview, the facility failed to ensure a resident received food that accommodated the resident's intolerances and preferencesfor one (1) of two (2) residents reviewed for choices. Resident Identifier: #84. Facility Census: 17.

Inspectors wroteBased on record review, observation and staff interview, the facility failed to ensure a resident was provided a physician ordered assistive device during mealtime in the dining room. This failed practice was a random opportunity for discovery, and had the potential to affect a limited number of residents residing in the long term care facility. Resident Identifier: #6. Facility Census: 117.

Inspectors wroteBased on records review and staff interviews, the facility failed to ensure a complete and accurate medical records. This failed practice was found true for one (1) out of (31) residents reviewed. Resident identifier: #61. Facility Census: 117 a) Resident #61 Documentation review of the medical record revealed a note by a medical provider reflected that resident has capacity and the assessment sheet scanned into the medical record demonstrated resident lacks capacity. Interview with the facility's Assistant Administrator on 01/18/26 at approximately 3:08 p.m., verified the inaccuracy of Resident #61's medical record.

Inspectors wroteBased on record review, staff interview, resident interview and observation, the facility failed to ensure call lights were operational and within the resident's reach. This failed practice had the potential to affect a limited number of residents. Resident identifiers: #9 and #84. Facility Census: 117.

Inspectors wroteBased on record review and staff interview, the facility failed to revise the care plan with a correct diagnosis for Resident #118. This was true for one (1) of 20 residents reviewed during the survey process. Resident Identifier: #118. Facility Census: 116. Findings Include: a) Resident #118On 10/21/25 at 10:00 AM, a record review was completed for Resident #118. The review found the care plan had not been revised with the correct diagnosis of restless leg syndrome. Under the focus area of Resident exhibits or is at risk for alterations in comfort related to chronic pain, neuropathy, left knee pain, bilateral calf pain, bladder spasms, Parkinsons disease, fibromyalgia, ganglion right wrist, spondylosis, osteroarthritis., the resident did not have a diagnosis of Parkinson's disease but did have a diagnosis of restless leg syndrome. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to provide an accurate and complete record for Resident #118's discharge and diagnosis for a medication. This was true for for one (1) of two (2) residents reviewed during the survey process. Resident Identifier: #118. Facility Census: 116. Findings Include: a1) Resident #118On 10/21/25 at 9:00 AM, a record review was completed for Resident #118. The review found the discharge plan documentation dated 07/09/25 was incorrect. Under section C entitled Recreation, a physician's order for treatment was listed as: Cleanse right 2nd toe amputation site with wound cleanser, pat dry, cover with betadine soaked gauze calcium alginate, wrap with kerlix. Upon further review, the resident did not have an amputation of the second toe. [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure one (1) of two (2) residents reivewed for pressure ulcers were not neglected. Resident #1 entered the facility without a pressure ulcer. He was discharged to another facility (nursing home). An assessment completed within 40 minutes after his discharge from the facility revealed a deep foul smelling wound to the coccyx. Resident #1 sustained actual harm. Resident identifier: #1. Facility Census: 118 Findings Include: a) Resident #1 Resident #1 was admitted to the facility on [DATE] from a critical illness recovery hospital. He had been at that facility from 01/22/25 - 02/18/25. He had previously been at another acute care hospital from [DATE] - 01/22/25. He was sent to the acute care hospital on [DATE] after his percutaneous endoscopic gastrostomy tube malfunctioned. [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure one (1) of two (2) residents reivewed for pressure ulcers received the apprpirate care to treat a wound to the coccyx. Resident #1 entered the facility without a pressure ulcer to the coccyx . He was discharged to another facility (nursing home). An assessment completed within 40 minutes after his discharge from the facility revealed a deep foul smelling wound to the coccyx. Resident #1 sustained actual harm. Resident identifier: #1. Facility Census: 118 Findings Include: a) Resident #1 Resident #1 was admitted to the facility on [DATE] from a critical illness recovery hospital. He had been at that facility from 01/22/25 - 02/18/25. He had previously been at another acute care hospital from [DATE] - 01/22/25. [...]

Inspectors wroteBased on record review, and staff interview the facility failed to provide accurate information to the receiving facility regarding skin condition. This failed practice was found true for (1) one of (3) three residents reviewed for transfer/discharge during the complaint survey. Resident identifier #1. Facility census: 118. Findings Include: a) Resident #1 A record review on 05/12/25 at 9:55 AM, revealed that Resident #1 was transferred from this facility to a different nursing home on [DATE] at approximately 5:20 PM. Further record review revealed the following general note dated 04/10/25 at 5:20 PM, that read as follows: Resident discharging from the facility at this time via ambulance transport to (Local State Nursing Home Named). Vital signs obtained and within normal limits. Skin check completed and no new issues identified. [...]

Inspectors wroteBased on observation, staff interview and record review, the facility failed to complete an accurate Minimum Data Set (MDS) related to dental status. This failed practice was found true for (1) one of (3) three residents reviewed for dental during the Long- Term Care Survey Process. Resident identifier #55. Facility Census: 112.

Inspectors wroteBased on record review, staff interview, observation and resident interview, the facility failed to develop and implement a comprehensive care plan for one (1) of two (2) resident's revieed for vision/hearing. Resident #62 had a hearing deficit/use of hearing aids. Resident identifier #62. Facility Census: 112.

Inspectors wroteBased on record review and staff interview, the facility failed to provide an activity program to meet the needs and interest of the residents. This failed practice was found true for (1) one of (2) two residents reviewed for activities during the Long-Term Care Survey Process. Resident identifier: #52. Facility Census 112. Findings Included: a) Resident #52 During the initial interview on 12/02/24 at 11:59 AM, Resident #52 stated, I would go to activities if I knew what was going on. I have no idea. A record review on 12/04/24 at 1:06 PM, of Resident #52's activity participation for the months of 09/2024, 10/2024, and 11/2024 revealed that Resident #52 only participated in (2) two group activities for the (3) month period. During an interview on 12/04/24 at 1:07 PM, The Activity Director stated, We offer her to come but she refuses. No, I do not have the refusals documented. [...]

Inspectors wroteBased on record review, resident interview and staff interview, the facility failed to ensure that one (1) of two (2) residents reviewed for vision/hearing received proper assuasive devices to maintain hearing abilities. Resident identifier #12. Facility census: 112.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure complete and accurate medical records for 2 of 27 residents reviewed. Resident identifiers: #8 and #55. Facility census: 112.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. The facility failed to initiate enhanced barrier precautions for a resident with reoccurring open wounds. This was a random opportunity for discovery that had the potential to affect a limited number of residents. Resident identifier: 67. Facility census: 112.

Inspectors wroteBased on observation, record review, resident interview and staff interview, the facility failed to promote self-determination through supporting the resident in choices that were significant to them. This deficient practice was true for three (3) of four (4) residents reviewed who did not receive care based on the resident's individual preference for care. Resident #93 did not receive grooming in accordance with requests made and/or customary routines for hair care, Resident #89 did not receive food preferences and Resident #77 did not receive shower preferences. Resident identifiers: Resident #93, #77 and #89. Census: 117.

Inspectors wroteBased on record review, observation, individual and staff interview, the facility failed to analyze or obtain supplemental information based on the comprehensive assessment to assist the resident in receiving dental services. This was true for one (1) of two (2) sampled residents reviewed for the care area of dental care. Resident identifier: Resident #93. Census: 117.

Inspectors wroteBased on observation and interview the facility failed provide an adequate amount of nutrition during a dinner meal on unit one and Resident #73. This was a random opportunity for discovery. Resident #73. Facility Census: 117.

Inspectors wroteBased on record reviews and staff interviews, the facility failed to ensure the completion of a new Preadmission Screening and Resident Review (PASARR) for residents with a newly added psychiatric diagnosis. This deficient practice had the potential to affect two (2) of three (3) residents reviewed for the PASAAR care area. Resident identifier: #13 and #75. Facility census: 117.

Inspectors wroteBased on resident interview, observation, and staff interview the facility failed to provide the necessary services to maintain good incontinence care. This was true for one (1) of three (3) residents reviewed for activities of daily living. It was discovered Resident #91 was wearing the wrong size incontinence brief. Resident identifier: #91. Facility census: 117.

Inspectors wroteBased on observation, record review and staff interview the facility failed to implement an ongoing resident centered activities program designed to meet the interest of and support the physical, mental and psychosocial well-being for resident #99 This practice was found true for one (1) of three (3) residents reviewed for the care area of activities during the Long Term Care Survey Process. Resident identifier # 99. Facility census 117 Finding Included: a) Resident #99 During the initial tour of the facility on 10/15/23 at 12:30 PM, Resident #99 was observed laying in the bed, the bed was against the wall. Resident was facing the wall and a window. There was a TV in the room turned toward the roommate; which was not turned on. The tv was not in a location where Resident #99 could see it. [...]

Inspectors wroteBased on staff interview, record review and observation the facility failed to provide a therapeutic diet which takes into account the resident's clinical condition, and preferences, when there is a nutritional indication. Resident #108 did not receive the correct diet of regular/liberalized diet for no oranges, orange juice, bananas, or tomatoes. This failed practice is true for one (1) of one (7) residents reviewed for nutrition. Resident identifier #108. Facility Census 117.