Hilltop Healthcare Rehabilitation and Skilled Nurs

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to have resident meals served within 45 minutes of the start of the posted scheduled mealtimes. This affected all 103 residents in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure that proper glove use and hygiene was completed during food service. This had the ability to affect all 26 residents on the [NAME] unit.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident prescribed an as needed (PRN) antipsychotic (AP) medication received a face-to-face visit with the provider before re-ordering the medication and failed to have documentation to support PRN AP medication use for 1 of 5 residents (R83) reviewed for unnecessary medications.

Inspectors wroteBased on interview and document review the facility failed to investigate an accident that resulted in injuries for 1 of 8 residents (R106) reviewed for accidents.

Inspectors wroteBased on interview and record review, the facility failed to meet the requirements for a bed hold notification, including having it in writing and including contact information for the area office of ombudsman for long term care, for 1 of 2 residents (R51) reviewed for hospitalization.

Inspectors wroteBased on interview and document review the facility failed to update a resident's care plan, including the resident's inability to safely smoke after a fall from wheelchair while smoking, for 1 of 1 resident (R106) reviewed for accidents.

Inspectors wroteBased on observation, interview and document review, the facility failed to monitor weights to identify possible congestive heart failure (CHF) exacerbation for 1 of 1 resident (R119) reviewed for quality of care.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure the care plan was followed to prevent potential aspiration for 1 of 9 residents (R99) reviewed for accidents.

Inspectors wroteBased on interview and record review, the facility failed to ensure timely implementation of a pharmacist recommendation and subsequent provider order to help prevent unnecessary medication use for 1 of 5 residents (R83) reviewed for unnecessary medications.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure the required nurse 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 information.

Inspectors wroteBased on interview and document review, the facility failed to consistently offer and provide a nutrient and/or calorie substantive snack after the dinner meal and before bedtime, leaving 15 hours between the evening and morning meals. This had the potential to affect all 107 residents at the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure psychotropic medication orders had an indication for use for 1 of 5 residents (R29) reviewed for unnecessary medications.

Inspectors wroteBased on record review and interview the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 3 of 5 residents (R26, R30, R29) reviewed for MDS completion.

Inspectors wroteBased on record review and interview, the facility failed to ensure a Level II Pre-admission Screening and Resident Review (PASARR) reassessment after 30 days was conducted, documented, and retained to ensure mental health needs were appropriately addressed or provided for 1 of 1 residents (R22) reviewed for PASARR.

Inspectors wroteBased on interview and document review, the facility failed to develop individualized and comprehensive care plans for for 2 of 2 residents (R30, R101) reviewed for pain and wound management.

Inspectors wroteBased on interview and document review, the facility failed to ensure that quarterly care conferences were completed for 1 of 1 resident (R17) reviewed for care conferences.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure weights were completed as ordered and failed to provide assessment and documentation before a visit to the emergency department for 1 of 2 residents (R3) reviewed for quality of care.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure that vitals were performed pre and post dialysis for 1 of 1 resident (R19) reviewed for dialysis care. R19's admission Minimum Data Set (MDS) dated [DATE], identified diagnoses of chronic kidney disease, atrial fibrillation, coronary artery disease, diabetes mellitus, and hypertension. Resident was cognitively intact. R19's care plan, undated, identified that R19 received dialysis and interventions included to check access site every shift to ensure dressing is clean, dry and intact, resident exhibits no signs/symptoms of infection, patency of access site palpating pulse of extremity, and checking for warmth and color of extremity. Meds/labs/treatments as ordered/accepted. The care plan did not address assessment of vitals pre or post dialysis. [...]

Inspectors wroteBased on interview, observation, and record review the facility failed to ensure competent administration of insulin occurred for 1 of 1 resident (R60) who was reviewed for insulin administration.

Inspectors wroteBased on record review and interview, the facility failed to ensure an indication for use was connected to ordered medications for 2 of 5 residents (R88, R407) reviewed for unnecessary medications.

Inspectors wroteBased observation, interview, and document review the facility failed to ensure medications were not left unsecured in resident accessible areas. In addition, the facility failed to ensure medications and biologics were properly stored in locked medication carts.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure care plan interventions were implemented for 1 of 3 resident (R1) reviewed who required the use of a transfer belt during transfers reviewed for falls. R1 sustained actual harm when staff failed to implement the use of a transfer belt during a transfer. R1 fell, fractured multiple ribs, sustained a left sided pneumothorax (free air around lung causing some lung collapse), a left sided hemothorax (blood around the lung cause some lung collapse) that led to chest tube placement, and was sent to the emergency department (ED) requiring medical treatment. The facility implemented a corrective action prior to the survey so the deficient practice was issued at past non-compliance.

Inspectors wroteBased on interview and document review, the facility failed to follow a Physician Orders for Life-Sustaining Treatment (POLST) to provide cardiopulmonary resuscitation (CPR) for 1 of 3 residents (R1), who wished to have CPR in the event of cardiopulmonary arrest (absence of pulse and respirations). This resulted in an immediate jeopardy (IJ) when R1 was found absent of pulse and respiration, CPR was not initiated and R1 died. The facility implemented immediate corrective action, and was issued at past non-compliance. The IJ began on [DATE] at 8:03 p.m. when licensed practical nurse (LPN)-A found R1 unresponsive in her room and did not initiate CPR per R1's wishes. The administrator and the director of nursing were notified of the IJ on [DATE] at 4:12 p.m. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to provide proper supervision during meals to prevent choking for 2 of 3 residents (R1, R2) who required 1:1 supervision during meals. This deficient practice resulted in an immediate jeopardy (IJ) for R1 and R2 when they were not provided 1:1 supervision during meals, and R1 had a coughing episode and R2 fell asleep with food in his mouth. The IJ began on 8/13/24 when R2 was found alone at the dining table sleeping with food in his mouth. The director of nursing (DON) and administrator were notified of the immediate jeopardy at 5:07 p.m. on 9/3/24. The IJ was removed on 9/4/24, but noncompliance remained at the lower scope and severity level of D - isolated, no actual harm with potential for more than minimal harm that is not immediate jeopardy.

Inspectors wroteBased on interview and document review, the facility failed to ensure completion of 12 hours of annual in-service training for 2 of 5 nursing assistants (NA-A, NA-D) reviewed for annual training.

Inspectors wroteBased on interview and document review, the facility failed to provide mandatory training on the facility specific QAPI (Quality Assurance and Performance Improvement) program to include goals and various elements of the program, how the facility intends to implement the program, staff's role in the facility's QAPI program, or how to communicate concerns, problems, or opportunities for improvement to the facility's QAPI program to all staff reviewed for QAPI training.

Inspectors wroteBased on observation, interview and document review, the facility failed to update care plans for 2 of X residents (R1, R52) and failed to hold resident care conferences for 5 of X residents (R15, R30, R51, R52, R114) reviewed for care planning.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications within the medications carts were properly labeled, stored, and not expired. This deficient practice had the potential to impact all residents who received stock medication, inhalation medications, insulins, or nitroglycerin at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure milk was maintained at a temperature to prevent foodborne illness. This had to ability to affect all residents who drank milk from the kitchen.

Inspectors wroteBased on interview and document review, the facility failed to offer and provide the most recent Centers for Disease Control (CDC) education regarding the potential risks and benefits of the pneumococcal vaccine for 3 of 5 residents (R18, R99, R114) reviewed for immunizations. This had the potential to affect all residents who were eligible for the pneumococcal booster.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the completed Minimum Data Set (MDS) was accurately coded to reflect hearing status for 1 of 2 residents (R1) and a medical condition for 1 of 2 residents (R52) reviewed for MDS accuracy.

Inspectors wroteBased on observation, interview, and document review the facility failed to ensure assessments, treatments and cares were provided and documented according to professional nursing standards for 1 of 1 resident (R30) reviewed for quality of care. In addition, the facility failed to properly track bowel movements and implement interventions for constipation for 1 of 7 residents (R52). R30's quarterly Minimum Data Set (MDS) dated [DATE], identified R30 was cognitively intact with diagnoses of diabetes type II, obstructive pulmonary disease, congestive heart failure, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. R30's careplan dated 1/30/24, included focus and interventions for non-compliance with showers, wearing brace, vital signs, and medications, but it did not include refusing cares for their super pubic catheter. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure staff were wearing personal protective equipment (PPE) when working with a resident with precautions, and failure to change gloves and perform hand hygiene for 2 of 7 residents (R114, R31) reviewed for infection control.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure the most recent survey results were readily accessible for residents or visitors. This had the potential to affect all 113 residents, their families, and any visitors who may have wished to review the information.

Inspectors wroteBased on interview and document review, the facility failed to notify the local hospital of Carbapenem-resistant Acinetobacter baumannii (CRAB)-positive status for 1 of 4 residents (R1) reviewed for infection control.