Hilltop Lodge Health and Rehabilitation Center

Inspectors wroteBased on interviews and record review, the facility failed to implement its policy to conduct thorough pre-hire criminal background checks for all staff as required and within the required timeframes.

Inspectors wroteThe facility had a census of 66 residents. The sample included 18 residents. Based on observation, interview, and record review, the facility failed to provide the nutritional dietary needs for the residents who received meals from the kitchen.

Inspectors wroteThe facility had a census of 66 residents. The sample included 18 residents. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in a sanitary condition for 66 residents who reside in the facility and receive meals from the facility's kitchen, placing them at risk for foodborne illness.

Inspectors wroteThe facility identified a census of 66 residents. The sample included 18 residents, with one resident reviewed for dignity. Based on observation and interviews, the facility failed to ensure Resident (R) 3 was covered when sitting in her Broda chair (specialized wheelchair with the ability to tilt and recline), with just a brief and a shirt on visible to the door. Findings Included:- R3's Electronic Medical Record (EMR) from the Diagnosis tab documented diagnoses of schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), cognitive communication deficit (an impairment in organization, sequencing, attention, memory, planning, problem-solving, and safety awareness), repeated falls, and dysphagia (swallowing difficulty). [...]

Inspectors wroteThe facility had a census of 66 residents. The sample included 18 residents. Based on observation, interview, and record review, the facility failed to revise the care plan with interventions to prevent falls and injury for Resident (R) 50.

Inspectors wroteThe facility identified a census of 66 residents. The sample included 18 residents, with three residents reviewed for positioning and mobility. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 41's washcloth or carrot (soft roll, designed to position severely contracted fingers away from the palm of the hand) was applied to his right hand to help prevent the risk of wounds related to his contractures.

Inspectors wroteThe facility had a census of 66 residents. The sample included 18 residents, with three residents reviewed for falls. Based on observation, interview, and record review, the facility failed to identify and implement interventions to prevent falls and injury for Resident (R) 50, who sustained 18 falls.

Inspectors wroteThe facility had a census of 66 residents. The sample included 18 residents. Based on observation, interview, and record review, the facility failed to label Resident (R) 47 insulin (a hormone that lowers the level of glucose in the blood) flex pens when initially opened for use.

Inspectors wroteThe facility identified a census of 66 residents. The sample included 18 residents. Based on record review, observations, and interviews, the facility failed to ensure oxygen saturation equipment was sanitized after each resident's use and further failed to ensure Resident (R) 45's, and R32's oxygen nasal cannulas, and R48 and R29's nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs) masks, and R2's continuous positive airway pressure (CPAP- ventilation device that blows a gentle stream of air into the nose to keep the airway open during sleep) masks were stored in a sanitary manner.

Inspectors wroteThe facility had a census of 66 residents. Based on observation, 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 identified a census of 69 residents with three residents reviewed for elopements. Based on record review, observation, and interview, the facility failed to identify and implement interventions and failed to provide adequate supervision to prevent an elopement for Resident (R) 1, who was cognitively impaired and at high risk for elopement. On 08/08/24 and 10/28/24 the facility assessed and documented R1 was at high risk for elopement but did not implement any interventions or update R1's plan of care to alert staff regarding R1's elopement risk. On 10/30/24 staff last saw R1 at 07:30 AM. At approximately 10:30 AM, the facility received a phone call from a community member stating an elderly man was walking on the grounds of the facility. The facility started a head count and realized R1 was not in the facility. [...]

Inspectors wroteThe facility had a census of 59 residents. The sample included 19 residents. Based on observation, record review, and interview, the facility failed to employ a full-time certified dietary manager for the residents who resided in the facility and received meals from the facility kitchen. This placed the residents at risk for inadequate nutrition.

Inspectors wroteThe facility had a census of 59 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to provide Resident (R) 55, R17, and R54 with sanitary indwelling urinary catheter (tube placed in the bladder to drain urine into a collection bag) care and R20 lacked an anchor for catheter tubing. These deficient practices placed the residents at risk for urinary tract infections and catheter related injury.

Inspectors wroteThe facility had a census of 59 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported Resident (R) 10's had multiple antidepressant (class of medications used to treat mood disorders) medications with a diagnosis of anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), R17 lacked blood sugar parameters, R55 lacked an end date for the use of an as needed (PRN) antianxiety (class of medications that calm and relax people), R20's recommended gradual dose reduction of psychotropic (alters mood or thought) medications lacked a physician response, and R38's use of antipsychotic (class of medications used to treat major mental conditions which cause a break from reality) for unapproved diagnosis. [...]

Inspectors wroteThe facility had a census of 59 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 10's antidepressant (class of medications used to treat mood disorders) medications had an approved indication, failed to ensure R55 had an end date for the use of an as needed (PRN) antianxiety (class of medications that calm and relax people), failed to ensure R20's recommended gradual dose reduction of psychotropic (alters mood or thought) medications were addressed, and failed to ensure R38's antipsychotic (class of medications used to treat major mental conditions which cause a break from reality) had an appropriate indication or the required physician documentation. This placed the residents at risk of receiving unnecessary psychotropic medication.

Inspectors wroteThe facility had a census of 59 residents. The sample included 19 residents with one reviewed for dignity. Based on observation, record review, and interview the facility staff failed to treat Resident (R) 54 with dignity, when staff failed to cover his urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag) urine collection bag with a privacy bag leaving the urine visible to other residents and guests in the facility. This placed the resident at risk for impaired dignity.

Inspectors wroteThe facility had a census of 59 residents. The sample included 19 residents. Based on observation, record review, and interview the facility failed to provide a safe environment in Resident (R) 37's room, when staff placed crinkled duct tape between the floor carpet seams. This placed the resident at risk of preventable accidents and an unhomelike environment.

Inspectors wroteThe facility had a census of 59 residents. The sample included 17 residents. Based on observation, interview, and record review, the facility failed to ensure Resident (R) 11 and R18 remained free of neglect and abuse. This deficient practice placed R11 and R18 at risk for injury and impaired physical and psychological well-being due to abuse, neglect, and/or mistreatment.

Inspectors wroteThe facility had a census of 59 residents. The sample included 17 residents. Based on observation, interview, and record review, the facility failed to report to the State Agency (SA) allegations of verbal and physical abuse and neglect for Resident (R) 11 and R18. This placed the residents at risk for ongoing abuse, neglect and mistreatment.

Inspectors wroteThe facility had a census of 59 residents. The sample included 17 residents. Based on observation, interview, and record review, the facility failed to fully investigate allegations of abuse, neglect and injuries of unknown origin for Resident (R) 11 and R18. This placed the residents at risk of ongoing abuse, neglect and mistreatment.

Inspectors wroteThe facility had a census of 59 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to develop a comprehensive care plan for Resident (R) 55 who had an indwelling urinary catheter (tube placed in the bladder to drain urine into a collection bag) and use of psychotropic (alters mood or thought) medication, and for R17 and R20's indwelling urinary catheter. This placed the residents at risk for impaired care due to uncommunicated care needs.

Inspectors wroteThe facility had a census of 59 residents. The sample included 17 residents. Based on observation, interview, and record review the facility failed to revise Resident (R) 19's Care Plan to include interventions related to pressure ulcers (PU-localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). This placed the resident at risk for impaired care due to uncommunicated care needs.

Inspectors wroteThe facility had a census of 59 residents. The sample included 17 residents, with four reviewed for activities of daily living (ADLs). Based on observation, record review, and interview, the facility failed to provide consistent bathing for Resident (R) 38. This placed R38 at risk for complications related to poor hygiene.

Inspectors wroteThe facility had a census of 59 residents. The sample included 17 residents, with five reviewed for non-pressure skin issues. Based on observation, record review, and interview, the facility failed to provide care and treatment in accordance with professional standards of practice for the care of non-pressure related skin injuries for Resident (R) 18 and R17. This placed the residents at risk for further skin injury and impaired healing.

Inspectors wroteThe facility had a census of 59 residents. The sample included 17 residents with seven reviewed for pressure injuries. Based on observation, record review, and interview, the facility failed to provide interventions to prevent the development of or promote healing for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) for Resident (R)11 and R19, who had or were at risk for pressure injuries. This placed R11 and R19 at risk for ongoing further pressure injury and related complications.

Inspectors wroteThe facility had a census of 59 residents. The sample included 17 residents with one reviewed for range of motion (ROM) services. Based on observation, interview, and record review the facility failed to provide ROM services to prevent further loss of mobility and function per the plan of care for Resident (R) 19. This placed the resident at risk for impaired mobility and decreased function.

Inspectors wroteThe facility had a census of 59 residents. The sample included 17 residents, with five reviewed for nutrition. Based on observation, record review, and interview, the facility failed to provide necessary nutritional assessments, notify and seek the involvement of the Registered Dietician (RD), and implement interventions to prevent unintended weight loss for Resident (R) 59, who had known weight loss before admission and continued loss after admission. The facility further failed to ensure that R19, who was on a pureed diet received the full nutritional benefit of what was served during the noon meal. This placed the residents at risk for ongoing weight loss and decline.

Inspectors wroteThe facility had a census of 59 residents. The sample included 17 residents. Based on observation, interview, and record review, the facility failed to provide Resident (R) 11 with the appropriate treatment and services to attain the highest practicable mental and psychosocial (interrelation of social factors and individual thought and behavior) well-being. This placed the resident at risk for unmet mental health care needs.

Inspectors wroteThe facility had a census of 59 residents. The sample included 17 residents. Based on observation, record review, and observation, the facility failed to obtain blood sugar parameters to ensure adequate monitoring for Resident (R) 17 who received insulin (a hormone that lowers the level of glucose in the blood) which placed the resident at risk of unnecessary medications and complications related to diabetes mellitus (DM-when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin).

Inspectors wroteThe facility had a census of 59 residents. The sample included 17 residents. Based on observation, record review, and interview, the facility failed to provide sanitary indwelling urinary catheter (tube placed in the bladder to drain urine into a collection bag) care per the standards practice related to infection prevention for Resident (R) 17, R55, and R54. This placed the affected residents at increased risk for urinary tract infections (UTI) and related complications.

Inspectors wroteThe facility identified a census of 59 residents with 24 residents who elected a full code (term used to indicate the desire to receive resuscitative measures in the event of cardiac arrest) status. Based on record review and interview, the facility failed to ensure staff provided cardiopulmonary resuscitation (CPR) to Resident (R) 1, who desired resuscitative measures as indicated by her full code status. At 11:08 AM on 12/30/23, staff entered R1's room and identified R1 was not breathing. Staff applied oxygen, but noted R1 had no vital signs at that time. The Registered Nurse on duty, LN G, called the emergency room (ER) at the local hospital and spoke with a physician who LN G referred to as R1's primary care physician (PCP). [...]

Inspectors wroteThe facility identified a census of 59 residents with nineteen cognitively impaired residents at risk for abuse, neglect, and exploitation. Based on record review, observation, and interview, the facility failed to implement interventions to protect nineteen cognitively impaired residents during an investigation of resident-to-resident abuse which occurred when Resident (R) 3 unwantedly and inappropriately touched and kissed R2, a cognitively impaired resident unable to consent. This placed the nineteen cognitively impaired residents who were unable to consent to sexual affections at risk for sexual abuse and psychosocial impairment.

Inspectors wroteThe facility identified a census of 59 residents with three residents reviewed for abuse, neglect, and exploitation. Based on record review, observation, and interview, the facility failed to prevent resident-to-resident abuse when Resident (R) 2 was unwantedly kissed on her hand and her mouth by R3. This deficient practice placed R2 at risk for unwanted sexual advances, anxiety, and impaired psychosocial functioning.

Inspectors wroteThe facility had a census of 63 residents. The sample included three residents reviewed for misappropriation and exploitation. Based on observation, record review, and interview, the facility failed to ensure Resident (R) 1 was free from misappropriation when an employee of the facility used R1's money to make purchases for R1 but did not purchase the items and could not produce receipts for the money spent. This deficient practice placed R1 at risk for ongoing misappropriation and exploitation.

Inspectors wroteThe facility identified census of 66 residents. Based on record review and interview, the facility failed to ensure the staff person designated as the Infection Preventionist, who was responsible for the facility's Infection Prevention and Control Program, completed the specialized training in infection prevention and control. This placed the residents at risk for lack of identification and treatment of infections.

Inspectors wroteThe facility identified a census of 66 residents. Based on observation, record review, and interviews, the facility failed to perform required food storage equipment checks, store food in a sanitary manner, and ensure kitchen appliances are wiped down daily. This deficient practice placed the residents at risk related to food borne illnesses and food safety concerns. Findings Included: During the initial kitchen walk-through on 06/13/22 at 07:15AM. The facility's walk-In freezer unit had water leaking from the freezer unit's cooling unit. The frozen vegetable packages stored on racks directly below the unit had ice from the leaking water An inspection of the reach-in freezer unit at 07:25AM revealed severe frosting inside the freezer. The unit temperature check log was missing checks for 6/10, 611, and 6/12. [...]

Inspectors wroteThe facility identified a census of 66 residents. Based on observation, record review and interview the facility failed to ensure staff followed infection control standard of practice. The facility failed to ensure laundry staff properly covered laundry when being delivered to residents. The facility failed to practice proper hand hygiene while care was provided to a resident. The facility staff failed to doff (remove gloves) after use and applied gel hand sanitizer to gloved hands. This placed the residents at increased risk for infection and transmission of communicable disease.

Inspectors wroteThe facility identified a census of 66 residents. The sample included 19 residents with three residents reviewed for dignity. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 24's urinary catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) drainage bag was placed in a privacy bag. The facility further failed to ensure R27's and R1's right to be treated with respect, dignity, and care during meals. This deficient practice placed the residents at risk for negative psychosocial outcomes and decreased autonomy and dignity.

Inspectors wroteThe facility identified a census of 66 residents. The sample included 18 residents. Based on observation, record review, and interview the facility failed to develop a care plan with guidance and interventions related to pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) /injury and enteral (within or via the small intestine) feeding for resident (R)44. This deficient practice had the potential to cause a decline in R44's physical, mental, and psychosocial well-being and independence due to uncommunicated care needs.

Inspectors wroteThe facility identified a census of 66 residents. The sample included 19 residents with one resident reviewed for limited range of motion (ROM- the full movement potential of a joint, usually its range of flexion and extension). Based on observation, record review, and interviews, the facility failed to implement splints to prevent a potential decrease in ROM/mobility and/or worsening of contractures (abnormal permanent fixation of a joint) for Resident (R) 25, which placed her at risk of loss of ability to perform activities of daily living (ADL's) and development of contractures.

Inspectors wrote- R115's Electronic Medical Record (EMR) from the Diagnoses tab documented diagnoses of hypertension (elevated blood pressure), unsteady on his feet, and repeated falls. The admission Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of five which indicated severely impaired cognition. The MDS documented that R115 required extensive of two staff members assistance for activities of daily living (ADL's). The MDS documented R115 had a history of falls prior to admission to the facility. The MDS documented R115 had one injury fall during the look back period. R115's Falls Care Area Assessment (CAA) dated 04/29/22 documented his balance problem as a cause for the injury fall during the look back period. [...]

Inspectors wroteThe facility identified a census of 66 residents. The sample included 18 residents with eight reviewed for bowel and bladder manangement. Based on observation, record review, and interviews, the facility failed to develop a bowel/bladder training program or resident specific toileting program for Residents (R)36. This deficient practice placed the residents at risk for complications related to incontinence. -The Medical Diagnosis section within R36's Electronic Medical Records (EMR) included diagnoses of hypertension (high blood pressure), muscle weakness, abnormalities of gait and mobility, need for assistance with personal cares, spinal stenosis (degenerative condition of the spine that could cause weakness and loss of use of extremities), major depressive disorder (major mood disorder), and sciatica (a severe pain that radiates from the back into the hip and outer side of the leg). [...]

Inspectors wroteThe facility identified a census of 66 residents. The sample included 19 residents which four residents reviewed for activities. Based on observation, record review, and interviews, the facility failed to provide the needed dementia (progressive mental disorder characterized by failing memory, confusion) care and services for Resident (R) 1, which placed her at risk for increased behaviors, confusion. decline in ability to maintain the highest practicable mental and psychosocial well-being.

Inspectors wroteThe facility reported a census of 66. The sample included 18 residents with five residents reviewed for unnecessary medications. Based on observations, interviews, and record reviews, the facility failed to provide reasoning for extended use with an as needed psychotropic medications (a class of medications which affect mood or thoughts) for Resident (R)36. The facility also failed to provide correct diagnosis for antipsychotic medication (class of medications used to treat psychosis and other mental emotional conditions) for R36. This deficient practice placed the residents at risk for ineffective treatment and unnecessary side effects. Findings Included: [...]