Hilltop Park Post Acute

Inspectors wroteBased on observations and interviews, the facility failed to ensure facility menus met the needs of residents and were followed. Specifically, the facility failed to ensure correct and adequate portion sizes were served according to the menu extensions.

Inspectors wroteBased on observations and interviews, the facility failed to provide a comfortable and homelike environment in three of four units. Specifically, the facility failed to:-Ensure the blinds, window sills, wall air conditioners and walls in resident rooms were clean and in good repair; and,-Ensure facility spas were in good working condition and the tile was in good repair.

Inspectors wroteBased on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards in three of three medication carts. Specifically, the facility failed to ensure:-Residents' medications were labeled and dated appropriately with the resident's name and the date the medication was opened; and,-Medications were labelled appropriately with medication labels from the pharmacy.

Inspectors wroteBased on observations, record review and interviews, the facility failed to store, prepare and distribute food in a sanitary manner in the main kitchen. Specifically, the facility failed to ensure staff washed hands and changed single use gloves appropriately while preparing, plating and distributing ready to eat food in the main kitchen.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease and infection on two of four units. Specifically, the facility failed to:-Ensure housekeepers cleaned high-touch areas, used proper dwell times, used proper cleaning and disinfecting techniques and performed hand hygiene when cleaning residents' rooms;-Ensure staff followed enhanced barrier precautions (EBP) when providing care); and, -Ensure residents did not enter the soiled linen room.

Inspectors wroteBased on observations and interviews, the facility failed to ensure two (#150 and #2) of five residents were provided with personal privacy out of 62 sample residents. Specifically, the facility failed to ensure:-Resident #2's room door and privacy curtain were closed during incontinence care; and,-Resident #150 was fully covered per her preference while being transported from the shower room in the shower chair back to her room.

Inspectors wroteBased on record review and interviews, the facility failed to revise and implement an effective discharge plan for two (#163 and #155) of three residents reviewed for discharge planning out of 62 sample residents. Specifically, the facility failed to:-Ensure the discharge planning process was documented, including the reason for discharge in Resident #163's electronic medical record (EMR); -Ensure the reconciled medication list, physician's orders and care plan provided to the resident at discharge were documented in Resident #163 and 155's EMRs;-Ensure Resident #155's discharge care plan was updated to include the resident's preference to transfer to another facility; and,-Ensure Resident #155's EMR contained documentation of the preparation provided to the resident prior to transfer to another facility in a form and manner the resident could understand.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure proper treatment and assistive devices to maintain visual abilities for one (#105) of three residents reviewed for ancillary services of 62 sample residents. Specifically, the facility failed to ensure Resident #105 received her eye glasses timely after an optometrist wrote a prescription.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide catheter care in accordance with standards of professional practice for one (#118) of three residents out of 62 sample residents. Specifically, the facility failed to ensure:-The urinary catheter was changed timely for Resident #118; and,-Resident #118, who was incontinent of the bladder, received appropriate treatment and services to prevent urinary tract infections (UTI) and to restore continence to the extent possible.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a response, action, and rationale to residents involved in group grievances. Specifically, the facility failed to:-Make prompt efforts to work with residents to resolve their food grievances; and;-Fully investigate and document grievance resolutions and corrective action.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to provide one of three residents (#5) out of 21 sample residents, with timely and necessary treatment and services to prevent and manage an avoidable, facility-acquired pressure injury that resulted in the development of a stage 4 coccyx wound with osteomyelitis. Resident #5, who had a diagnosis of paraplegia, was admitted on [DATE] with intact skin. The resident was discovered with an unstageable pressure injury on his coccyx on 11/28/23, 14 days after admission. By 1/2/24, the pressure injury had progressed to a stage 4 pressure injury (full-thickness tissue loss with exposed bone, tendon, or muscle). And, on 6/6/24, x-rays revealed the presence of osteomyelitis, inflammation of the bone due to infection, requiring an extended course of antibiotic treatment. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure that all nursing staff had the specific competencies and skill sets necessary to identify, intervene, and notify the physician of residents' acute changes of condition related to wound development and treatment measures such as providing wound care and management of pressure relieving mattresses. This affected all residents with pressure wounds or those at risk for developing a pressure wound and contributed to Resident #5's pressure wound from worsening to a Stage 4 pressure wound with osteomyelitis (infection at the bone). Cross-reference F686 for failure to prevent worsening of a pressure injury. [...]

Inspectors wroteBased on record review and interviews, the facility failed to develop, implement and maintain an effective training program for all staff based on the facility assessment and resident population. Specifically, the facility failed to: -Ensure all direct and non-direct care staff received training in quality assurance and quality improvement (QAPI), compliance and ethics and resident rights; -Ensure all direct and non-direct care staff received training in all components of abuse training including abuse prevention, identification and types of abuse; -Ensure all certified nurse aides (CNA) received at least 12 hours of annual in-service training.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure resident rights were promoted and dignity was maintained for seven (#10, #15, #17, #18, #19, #20, and #21) of seven residents out of 21 sample residents.

Inspectors wroteBased on record review and interviews, the facility failed to ensure each resident was permitted to remain in the facility and not transfer or discharge for three (#6, #4 and #3) of four residents reviewed for discharge out of 21 sample residents. Specifically, the facility failed to: -Have documentation from Resident #6's physician regarding the reason for the resident's facility-initiated discharge; -Document the specific resident need(s) that could not be met at the facility, the facility's attempts to meet the resident's needs and the services available at the receiving facility to meet the resident's need(s) for Resident #6; -Document the discharge planning process in Resident #6's electronic medical record (EMR); -Ensure Resident #6's necessary information, including the resident's comprehensive care plan goals, was provided to the receiving facility; [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure a discharge summary was in place for three (#2, #3 and #4) of four residents reviewed for discharge out of 21sample residents. Specifically, the facility failed to ensure discharge summaries included a recapitulation of the resident's stay and/or a final summary of the resident's status was completed for Resident #2, #3 and #4.

Inspectors wroteBased on record review and interviews, the facility failed to provide evidence that a quarterly statement was provided to the resident and/or resident representative for two (#9 and #12) of three residents reviewed for personal funds out of 21 sample residents. Specifically, the facility failed to: -Provide Resident #9 and Resident #12 or their legal representatives a copy of the resident's personal funds financial statement on at least a quarterly basis; -Ensure Resident #9 and Resident #12 or their legal representatives reviewed and signed the form required to give the facility authorization to manage the resident's personal funds; and, -Ensure Resident #9 and Resident #12 or their legal representatives were informed when the resident's total funds reached an amount that required a spend down.

Inspectors wroteBased on record review and interviews, the facility failed to provide notice of discharge to the resident or their representative and the Office of the State Long-term Care Ombudsman at least 30 days before the resident's discharge for one (#6) of four residents reviewed for discharge out of 21 sample residents. Specifically, the facility failed to provide Resident #6 an appropriate written notice of discharge from the facility that included: -The reason for transfer or discharge; -The location to which the resident was being transferred or discharged ; -A statement of the resident's appeal rights, including the name, address (mailing and email) and telephone number of the entity which receives such requests; and, -Information on how to obtain an appeal form and assistance in completing the form and submitting the appeal-hearing request.

Inspectors wroteBased on record review and interviews, the facility failed to provide and document sufficient preparation and orientation for one (#2) of three residents out of 21 sample residents to ensure a safe discharge from the facility. Specifically, the facility failed to: -Provide Resident #2 and his representative with the correct information regarding the resident's nutritional and tube feeding needs when the resident was discharged ; -Provide Resident #2 and his representative with discharge education or training related to the resident's feeding tube; and, -Provide Resident #2 and his representative with a discharge summary and discharge instructions in a language they understood.

Inspectors wroteBased on record review and interviews, the facility failed to develop and implement an effective discharge planning process for two (#16 and #2) of four residents reviewed for discharge planning out of 21 sample residents. Specifically, the facility failed to: -Ensure the discharge planning process was documented in Resident #16's and Resident #3's electronic medical records (EMR); and, -Ensure the interdisciplinary team (IDT) was a part of the ongoing discharge process for Resident #16 and Resident #3.

Inspectors wroteBased on record review and interviews, the facility failed to assist residents in making transportation arrangements to and from the source of service for one (#9) of one resident reviewed for medical transportation out of 21 sample residents. Specifically, the facility failed to assist Resident #9 with scheduling medical transportation by a gurney for a follow-up appointment with a urologist (a physician specializing in conditions that affect the urinary tract).

Inspectors wroteBased on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to quality of care, specifically pressure injuries.

Inspectors wroteBased on interviews, observations, and record review, the facility failed to ensure residents received necessary respiratory care and services per professional standards of practice for four (#174, #99, #20, and #95) of four residents reviewed for respiratory care out of 46 sample residents. The facility failed to have an effective system to ensure the residents who required specialized respiratory care received such care in a manner consistent with professional standards of practice. -The facility failed to maintain the necessary respiratory supplies to provide for and manage Resident #174's respiratory needs. Resident #174 had a tracheostomy tube (trach tube) with an inner cannula. He was readmitted from the hospital on 3/3/24 with a supply of 3 inner cannulas. [...]

Inspectors wroteBased on observations and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections on one of two units. Specifically, the facility failed to follow proper personal protective equipment (PPE) procedures when entering residents' isolation rooms.

Inspectors wroteBased on record review, observations and interviews the facility failed to ensure seven (#25, #39, #40, #66, #70, #75 and #115) of 10 residents out of 46 sample residents were kept free from neglect. Specifically, the facility failed to provide adult briefs, wipes, linens, towels and washcloths to Resident #25, #39, #40, #66, #70, #75 and #115 as required to maintain their highest practicable well-being.

Inspectors wroteBased on observation and interviews, the facility failed to ensure medications and biologicals were stored in accordance with professional standards for four of six medication carts. Specifically, the facility failed to ensure: -Medication carts were cleaned with no loose medication; and, -Food was not stored in the medication carts.

Inspectors wroteBased on observations and interviews, the facility failed to ensure medications were dispensed according to professional standards of practice for two (#25 and #2) of 10 residents reviewed for medication administration out of 46 sample residents. Specifically, the facility failed to ensure nurses did not leave medications unattended at residents' bedsides.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#115) of three residents out of 46 sample residents received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to administer insulin (medication used to level blood glucose) in a timely manner per the physician orders.

Inspectors wroteBased on observations, interviews and record review, the facility failed to assist residents with obtaining vision devices for one (#30) of two residents reviewed for vision/ancillary services out of 46 sample residents. Specifically, the facility failed to ensure Resident #30 received glasses in a timely after an optometry visit.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure residents with a feeding tube received appropriate treatment and services for one (#102) of three residents reviewed with a feeding tube out of 46 sample residents. Specifically, the facility failed to ensure Resident #102 received her tube feeding administrations as ordered by the physician.

Inspectors wroteBased on record review and interviews, the facility failed to conduct a preadmission screening resident review (PASRR) for individuals remaining in a facility 30 days past provisional admission approval for one (#3) of three residents reviewed for PASRR out of 10 sample residents. Specifically, the facility failed to submit a new PASRR level I once an automatically approved provisional admission from a hospital had expired for Resident #3 after she resided in the facility for more than 30 days.

Inspectors wroteBased on record review and staff interviews, the facility failed to implement policies and procedures related to pneumococcal immunizations for six (#1, #2, #3, #5, #6 and #8) of eight residents reviewed for immunizations out of eight sample residents. Specifically, the facility failed to: -Offer Resident #1 and #8 the pneumococcal vaccine upon admission; -Offer additional doses of the pneumococcal vaccine to Resident #2, #3 and #5; and, -Have a signed consent of a refusal for Resident #6.

Inspectors wroteBased on interviews, record review, and document review, the facility failed to ensure residents were informed in advance and in writing of items and services not covered under Medicaid and of the right to an expedited review of service termination for 3 (Residents #256, #56, and #92) of 3 sampled residents reviewed for advance beneficiary notification (ABN). This deficient practice had the potential to place unexpected financial responsibility on residents and/or resident representatives and for residents/representatives to be unaware of the right to appeal service denials.

Inspectors wroteBased on interviews, record reviews, document review, and facility policy review, it was determined that the facility failed to ensure a level I Pre-admission Screening and Resident Review (PASRR) was completed prior to admission to facilitate appropriate placement and care for 2 (Resident #92 and Resident #52) of 3 sampled residents reviewed for PASRR.

Inspectors wroteBased on interviews, record reviews, document review, and facility policy review, the facility failed to develop a care plan to address the need for wound care and related monitoring for 1 (Resident #156) of 3 sampled residents reviewed for wounds.

Inspectors wroteBased on observations, record review, interviews, and facility policy review, the facility failed to ensure baths/showers were regularly provided to maintain good hygiene for 1 (Resident #87) of 3 dependent sampled residents reviewed for activities of daily living (ADLs).

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to ensure that influenza vaccination was given to one (Resident #52) of five residents reviewed for vaccinations.