Hilltop Manor Nursing Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an environment free from accident hazards for Resident (R) 1. On 03/20/26 at approximately 10:30 AM, Certified Nurse Aide (CNA) M retrieved a lift sling to assist R1 with a full-body mechanical lift. CNA M took the top lift sling from the pile without verifying it was the appropriate sling for R1. CNA M and CNA N then began transferring R1 with a full body mechanical lift using the incorrect sling, which was inadequate for R1's size. The sling had a maximum weight capacity of 150 pounds, and R1 weighed 255 pounds. During the transfer the lift sling ripped at the strap, and the resident fell to the floor, resulting in a left hip and pelvis fracture. This failure placed R1 in immediate jeopardy.

Inspectors wroteThe facility reported a census of 36 residents. Based on observation, record review, and interview, the facility failed to ensure that meals were served at a safe and appetizing temperature.

Inspectors wroteThe facility reported a census of 36 residents. The sample included 12 residents. Based on interviews, observation and record review, the facility failed to utilize Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) when providing direct care to a Resident (R) 3 with a feeding tube (tube for introducing high-calorie fluids into the stomach). The facility further failed to ensure adequate hand hygiene before and after personal care for R3, and R23. The facility failed to store nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs) mask and oxygen nasal cannula in a sanitary manner for R30 and R1. Additionally, the facility failed to sanitize mechanical lift in-between residents' use. [...]

Inspectors wroteThe facility reported a census of 36 residents; the sample included 12 residents sampled. Based on interviews and record review, the facility failed to ensure residents received the opportunity to participate in the care planning process when staff failed to invite Residents (R) 1 and R30 or their responsible party to care plan meetings.

Inspectors wroteThe facility reported a census of 36 residents. The sample included 12 residents with one resident reviewed for self-administration of medications Based on observation, interview, and document review the facility failed to assess Resident (R) 30 for the ability to safely self-administer Mucinex (medication used to treat congestion) and Flonase ( nasal spray to treat nasal congestion and allergies) and keep at the bedside. The facility additionally failed to ensure an order to keep those medications at the bedside and self-administer.

Inspectors wroteThe facility had a census of 36 residents; the sample included 12 residents, including one resident reviewed for accommodation of needs. Based on observation, record review, and interview, the facility failed to ensure Resident (R)23's foot platform remain attached to her electric wheelchair.

Inspectors wroteThe facility reported a census of 36 residents; the sample included 12 residents. Based on observation, interview, and record review, the facility failed to obtain valid advanced directives (a legal document in which a person specified what actions should be taken for their health,) or assess the wishes of Resident (R) 23 related to end-of-life care.

Inspectors wroteThe facility identified a census of 36 residents. The sample included 12 residents, with five residents reviewed for unnecessary medications. Based on observation, record review, and interviews, the facility failed to ensure a 14-day stop time for the use of an antidepressant (a class of medications used to treat mood disorders) for Resident (R) 5 on an as needed (PRN) basis, as required.

Inspectors wroteThe facility had a census of 36 residents. The sample included 12 residents. Based on interview, observation, and record review, the facility failed to provide services to meet professional standards of care when staff failed to ensure Resident (R) 4's Electronic Medical Record (EMR) contained appropriate documentation for the paranoid schizophrenia (a mental disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought) diagnosis.

Inspectors wroteThe facility reported a census of 36 residents. The sample included 12 residents with three residents reviewed for activities of daily living (ADLs). Based on observation, interviews, and record review the facility failed to offer and provide assistance with nail care and facial hair removal for Resident (R) 4.

Inspectors wroteThe facility reported a census of 36 residents; the sample included 12 residents with three residents reviewed for accident hazards. Based on observation, interview, and record review, the facility failed to ensure an environment free from accident hazards when staff failed to support the feet of two residents, Resident (R) 5 and R31, off the ground during staff-assisted wheelchair locomotion.

Inspectors wroteThe facility had a census of 41 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to identify causal factors for falls, provide adequate supervision, and implement effective interventions to prevent avoidable accidents for Resident R (32) when he had multiple falls over various dates, which resulted in fractures, contusions, increased pain, and multiple trips to the hospital. The facility also failed to identify causal factors and implement interventions to prevent falls for R22. These failures caused actual harm to R32 and placed R22 and other residents at risk for continued accidents and injuries.

Inspectors wroteThe facility had a census of 41 residents. The sample included 12 residents. Based on record observation, record review, and interview, the facility failed to identify Resident (R) 32's multiple unwitnessed falls with fractures as possible neglect and report to the State Agency (SA) as required. This placed the resident at risk for unidentified and/or ongoing abuse.

Inspectors wroteThe facility identified a census of 41 residents. The sample included 12 residents with two residents sampled for hospitalization and one resident sampled for discharge. Based on observation, record review, and interview, the facility failed to provide written notice of transfer as soon as practicable to Resident (R) 13 or their representative for their facility-initiated transfers and/or discharge. This deficient practice had the risk of miscommunication between the facility and resident/family and possible missed opportunity for healthcare service for R13.

Inspectors wroteThe facility had a census of 41 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to revise the care plan with effective interventions for Resident (R) 32 and R22 who had falls with injuries. This placed R32 and R22 at risk for ongoing falls and injury due to uncommunicated care needs.

Inspectors wroteThe facility reported a census of 41 residents, with all receiving meals from one main kitchen. Based on observation, interview, and record review the facility failed to store and serve food in in a sanitary manner when observation revealed undated foods in the kitchen refrigerator and when dietary staff used gloves but cross-contaminated the gloves during food service.

Inspectors wroteThe facility census totaled 41 residents with 12 residents included in the sample. Based on observation, interview and record review the facility failed to revise the comprehensive care plan to include Resident (R) 19's wandering and risk of elopement.

Inspectors wroteThe facility reported a census of 41 residents with 12 included in the sample. Based on observation, interview and record review the facility failed to provide adequate supervision for a wandering Resident (R) 19, identified as at risk of elopement, which placed her at risk for wandering into unsafe areas/situation.

Inspectors wroteThe facility census totaled 41 residents with 12 sampled including five reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure the consultant pharmacist identified the lack of monitoring for potential side effects in the use of antipsychotic medications received, when facility staff did not complete an Abnormal Involuntary Movement Scale (AIMS) assessment for Resident (R) 26. Findings Included: - The 06/14/22 Physician's Orders in the Electronic Health Record (EHR) documented R26 with diagnosss of dementia (progressive mental disorder characterized by failing memory, confusion) and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness). [...]

Inspectors wroteThe facility census totaled 41 residents with 12 sampled including five reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to ensure adequate monitoring of potential side effects for antipsychotic medications received, when facility staff did not obtain an Abnormal Involuntary Movement Scale (AIMS) assessment for Resident (R) 26. Findings Included: - R26's 06/14/22 Physician's Orders in the Electronic Health Record (EHR) documented diagnosis of dementia (progressive mental disorder characterized by failing memory, confusion) and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness). The 02/02/22 Annual Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of nine, which indicated moderate cognitive impairment. [...]