Hilltop Skilled Nsg & Rehab

Inspectors wroteBased on observation, interview, and record review the facility failed to provide timely antibiotic treatment and provide perineal care after toileting for one resident (R3) out three residents reviewed for infection control in a sample list of four residents.

Inspectors wroteBased on observation, interview and record review the facility failed to provide palatable foods for residents. This failure has the potential to affect all 64 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to prevent cross contamination during meal services. This failure has the potential to affect all 64 residents residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the safety of four (R1, R2, R4, R5) residents through the use of extension cords for medical devices out of four residents reviewed for physical environment in a sample list of five residents.

Inspectors wroteBased on interview and record review the facility failed to accurately complete a minimum data set (MDS) assessment for one of 24 residents (R31) reviewed for MDS in the sample of 28.

Inspectors wroteBased on observation, interview, and record review the facility failed to accurately transcribe and administer diabetic wound care as ordered for one of six residents (R13) reviewed for wounds in the sample list of 28.

Inspectors wroteBased on observation, interview, and record review the facility failed to perform hand hygiene prior to applying personal protective equipment and prior to wound care, disinfect scissors during wound care, and failed to ensure a urinary catheter was kept off the floor for two of 24 residents (R13, R49) reviewed for infection control in the sample list of 28.

Inspectors wroteBased on interview and record review the facility failed to properly implement fall interventions for one of three (R1) residents reviewed for falls on the sample list of four. This failure resulted in R1 falling and sustaining a left femoral neck fracture. This past noncompliance occurred from 5/1/25 through 5/9/25. Findings Include: The Full QA Report dated 5/1/25 documents R1 had a witnessed fall on 5/1/25 at 12:05 AM. R1 attempted to stand up from her wheelchair and fell to the ground. R1's chair alarm did not sound. R1 displays poor dynamic sitting/standing balance as well as impulsiveness related to her advanced Dementia diagnosis. V4 Certified Nurses Assistant (CNA) was walking by the hallway and observed R1 attempt to stand then lose her balance and fall to the ground. V4 notified the nurse on duty (V3 Registered Nurse RN). [...]

Inspectors wroteBased on interview and record review the facility failed to protect the right of a resident to be free from misappropriation of their medication. This failure had the potential to affect one of three residents (R2) reviewed for misappropriation on the sample list of five. This past noncompliance occurred from 4/16/25 through 4/24/25. Findings Include: The facility's Abuse Policy dated 9/15/23 documents the facility affirms the right of residents to be free from misappropriation of property. Misappropriation of resident property is defined as the deliberate misplacement, exploitation, or wrongful temporary or permanent use of a resident's belongings without the resident's consent. The facility's Controlled Substances policy dated 5/11/20 documents, controlled substances are reconciled upon receipt, administration, disposition, and at the end of each shift. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide foods that were palatable and at appropriate temperatures, and failed to provide a meal for a resident for five of nine residents (R8, R20, R30, R53, R163) reviewed for dining in a sample list of 43 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain cleanliness of resident's mattresses. This failure affects one resident (R3) out of 24 reviewed for environmental cleanliness on the sample list of 43.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately encode residents' minimum data set assessments concerning dental conditions. This failure affects two residents (R16 and R41) out of three reviewed for dental conditions on the sample list of 43.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive care plan to include residents with denture problems. This failure affects two residents (R16 and R41) out of three reviewed for dental problems on the sample list of 43.

Inspectors wroteBased on interview and record review the facility failed to complete a recapitulation of stay for one (R58) resident out of one resident reviewed for discharge in a sample list of 43 residents.

Inspectors wroteBased on interview and record review the facility failed to provide safe and adequate assistance with showers to a dependant resident. This failure affected one of one resident (R39) reviewed for Activities of Daily Living on the sample list of 43. Findings Include: R39's Medical Diagnoses List dated October 2024 documents R39 is diagnosed with Lumbar Spondylopathies, Spinal Cord Injury of Lumbar Region, Neuromuscular Dysfunction of Bladder, Depression, Left and Right foot Drop, and Neurogenic Bowel. R39's Minimum Data Set, dated [DATE] documents R39 is cognitively intact. No documentation was entered for R39's showering needs. R39's Minimum Data Set, dated [DATE] documents R39 requires partial to moderate assistance with showering and lower body dressing. R39 requires substantial or maximum assistance for putting on or taking off footwear. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure resident medical equipment was properly utilized for three (R8, R18, R42) residents out of three residents reviewed for safety in a sample list of 43 residents.

Inspectors wroteBased on interview and record review, the facility failed to obtain physician responses from pharmacist recommendations in a timely manner, and failed to develop their pharmacist policy to include timeframes for the steps in the monthly medication regimen reviews. This failure affects two residents (R16 and R44) out of five reviewed for unnecessary medications on the sample list of 43.

Inspectors wroteBased on observation, interview and record review the facility failed to honor one (R260) residents food preferences out of nine residents reviewed for meal service in a sample list of 43 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to serve a resident meals consistent with a resident's allergies for one of nine residents (R6) reviewed for meal service in a sample list of 43 residents.

Inspectors wroteBased on interview and record review, the facility failed to document evaluations to determine cognitively impaired residents' capacity to consent to a known sexual relationship, failed to develop their policy on intimate resident behavior to include the criteria for initial evaluation and frequency with which a cognitively impaired resident's capacity to consent to an intimate relationship is to be evaluated, and to specify where and how the evaluations and determinations would be documented and maintained. This failure affects two (R1, R2) residents and has the potential to affect 22 additional cognitively impaired residents (R5 through R26) on the sample list of 26 reviewed for cognitive capacity.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident was free from sexual abuse by another resident. This failure affects two residents (R1, R2) reviewed for sexual abuse on the sample list of 26.

Inspectors wroteBased on interview and record review, the facility failed to develop residents care plans to include an intimate relationship and the need for privacy. This failure affects two residents (R1, R2) out of 5 reviewed for care plans on the sample list of 26.

Inspectors wroteBased on observation, interview and record review the facility failed to protect the resident's right to be free from sexual abuse by another resident and verbal/mental abuse by a staff member for four of seven residents (R1, R2, R3 and R5) reviewed for abuse in the sample list of seven residents. These failures resulted in R2 crying, feeling uncomfortable, and removing herself from shared areas with R1 after R2 was sexually abused by R1 and R5 experiencing feelings of isolation and fear after a staff member verbally/mentally abused R5.

Inspectors wroteBased on observation, interview and record review the facility failed to protect residents (R2, R3) from inappropriate behaviors and sexual abuse by another resident (R1) after an abuse allegation. This failure affects three of seven residents (R2, R3 and R1) reviewed for abuse in the sample list of seven. This failure resulted R2 crying, feeling uncomfortable, and removing herself from shared areas with R1 after R1 was left unsupervised and R1 sexually abused R2.

Inspectors wroteBased on interview and record review the facility failed to report an allegation of physical abuse to the Abuse Coordinator timely for two of seven residents (R1, R5) reviewed for abuse in the sample list of seven.

Inspectors wroteBased on observation, interview and record review the facility failed to provide denture care assistance for two (R1 and R3) of three residents reviewed for activities of daily living from a total sample list of seven residents reviewed.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain a safe, sanitary, and comfortable environment by failing to prevent ongoing water leakage through the roof and mold-like growth in the shower rooms and on ceiling tiles. This failure has the potential to affect all 62 residents residing in the facility. Findings Include: On [DATE] at 9:35 AM there was black mold-like substance on the East Hall shower room ceiling vent grate. There was also black and orange mold-like substance on the shower stalls wall and floor. The caulk was peeling off and the black mold like substance was growing underneath. On [DATE] at 9:40 AM one 2'x2' ceiling tile in front of room [ROOM NUMBER] and 106 was missing and the tile next to that spot appeared to have been saturate with water at one point, was bulging downward towards the floor and was discolored and brown. On [DATE] at 9: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide individualized fall interventions and provide safe access for communication/response to resident's requests for care. This failure affects one resident (R5) of five residents reviewed for fall interventions in the sample of five.

Inspectors wroteBased on observation, interview and record review the facility failed to provide adequate supervision to prevent a resident from leaving the building resulting in a fall outside on the sidewalk (R52) and failed to remove a mechanical lift sling from underneath a resident to prevent sliding in the wheelchair (R18) for two of eight residents (R52, R18) reviewed for accidents in the sample list of 34. This failure resulted in R52 exiting the building unaccompanied and falling resulting in abrasions to R52's face, hand and knee and a bruise to R52's face.

Inspectors wroteBased on observation, interview, and record review the facility failed to prepare and distribute food under sanitary conditions. This failure has the potential to affect all 61 residents residing in the facility.

Inspectors wroteBased on interview and record review the facility failed to develop, implement and maintain an ongoing quality assurance performance improvement program over the past 12 months. This failure has the potential to affect all 61 residents of the facility.

Inspectors wroteBased on interview and record review the facility failed to hold quarterly quality improvement meetings over the past 12 months. This failure has the potential to affect all 61 residents of the facility.

Inspectors wroteA. Based on record review and interview the facility failed to initiate a water management program. This failure has the potential to affect all 61 residents residing at the facility. B. Based on observation, interview and record review the facility failed to prevent potential cross contamination during incontinence care for one of two residents (R50) reviewed for incontinence care in the sample list of 34. Findings Include: a.) The facility's Long-Term Care Facility Application for Medicare and Medicaid dated 11/1/23 documents 61 residents reside in facility. The facility's policy Legionella Water Management Program last revised July 2017 (not reviewed annually) states Our facility is committed to the prevention, detection, and control of water-borne contaminants, including Legionella. The water management team will consist of at least the following personnel: [...]

Inspectors wroteBased on interview and record review the facility failed to assess the need for Psychotropic medications for five of five residents (R52, R9, R50, R18, R24) reviewed for unnecessary medications in the sample list of 34.

Inspectors wroteBased on record review and interview the facility failed to offer/administer Pneumococcal vaccines for four residents (R23, R29, R8, R49) of five residents reviewed for Vaccines in a sample list of 34.

Inspectors wroteBased on record review and interview the facility failed to offer/administer Sars-Co-V2 (COVID) vaccines for four residents (R23, R29, R8, R49) of five residents reviewed for vaccines in a sample list of 34.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a call light was in reach for one resident (R213) of 16 residents reviewed for call lights in a sample list of 34. Findings Include: R213's Order Summary Report printed 11/1/23 at 3:10PM documents R213 was admitted to the facility 10/21/23 with diagnoses of Extensive Heart and Lung Disease and chronic Kidney Disease for Hospice care. On 10/30/23 at 3:20 PM R213 was resting in her bed. R213 stated I can't get to my call light. I'm thirsty, I want some ice, and I need straightened out in bed and I can't reach my call light. R213's call light was observed on the floor between the left side of the bed and the wall. No staff were observed in the room or the hall outside R213's room. On 10/31/23 at 3:15 PM R213 was resting in her bed. [...]

Inspectors wroteBased on interview and record review the facility failed to notify the resident's representative of a change in condition for one resident (R20) of 16 residents reviewed for condition change in a sample list of 34 residents.

Inspectors wroteBased on interview and record review the facility failed to notify the resident's representative of a transfer to the hospital for one resident (R20) of 16 residents reviewed for condition change in a sample list of 34 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) level I screening was completed for two (R24 and R37)of two residents reviewed for PASARR level I screenings with serious mental illnesses and prescribed anti-psychotic medication from a total sample list of 34 residents reviewed. Findings Include: 1. R24's level I PASARR dated 7/1/19, documents that a level II PASARR is not required due to R24 not having a SMI (Severe Mental Illness) diagnosis upon admission to the facility on 7/2/19. R24's diagnosis sheet dated 11/20/20 documents a new diagnosis of Psychosis. R24's diagnosis sheet dated 1/5/23 documents a new diagnosis of Schizoaffecive disorder. [...]

Inspectors wroteBased on interview and record review the facility failed to update a care plan with resident's significant weight loss for two of 16 residents (R11, R20) reviewed for care plans in the sample list of 34.

Inspectors wroteBased on observation, interview and record review the facility failed to assist with/provide ADL (Activities of Daily Living) care for two of three residents (R11, R50) reviewed for ADLs in the sample list of 34.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pressure ulcer treatments and relieve pressure while up in the wheelchair for one (R18) of four residents reviewed for pressure ulcers on the sample list of 34.

Inspectors wroteBased on observation, interview and record review the facility failed to perform complete incontinence care for one of two residents (R50) reviewed for incontinence care in the sample list of 34.

Inspectors wroteBased on observation, interview and record review the facility failed to implement nutritional interventions for a resident with significant weight loss for one of four residents (R11) reviewed for weight loss in the sample list of 34.

Inspectors wroteBased on observation, interview and record review the facility failed to provide oxygen therapy as ordered and failed to change oxygen tubing weekly for one (R17) of one residents reviewed for oxygen therapy from a total sample list of 34 residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess the risk for entrapment for the use of a bed rail for one of one resident (R18) reviewed for bed rails on the sample list of 34.

Inspectors wroteBased on observation, interview and record review the facility failed to securely store a schedule four medication and failed to dispose of undated insulin for three (R4, R47 and R213) of three residents reviewed for medication storage from a total sample list of 34 residents.

Inspectors wroteBased on observation, interview and record review the facility failed to post daily staffing. This failure has the potential to affect all 61 residents residing in facility.

Inspectors wroteBased on observation, interview and record review the facility failed to provide appropriate and sufficient services to prevent urinary tract infection (UTI) for a resident with an indwelling urinary catheter. The facility also failed to obtain an acceptable urine specimen from a resident with an indwelling urinary catheter from 9/26/23 to 10/11/23(2 weeks) resulting in a delay of treatment. These failures affects one resident (R4) of three residents reviewed for catheter care in a sample list of seven residents.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain infection control practices for one (R4) resident on contact isolation precautions for Extended Spectrum Beta-Lactamase (ESBL) in urine out of three residents reviewed for catheters in a sample list of seven residents.

Inspectors wroteBased on observation, interview and record review the facility failed to employ a qualified director of food and nutrition services. This failure has the potential to affect all 60 residents residing in facility.

Inspectors wroteBased on observation, interview and record review the facility failed to properly label and store refrigerated food products, failed to properly store thawed meat to prevent meat juice from dripping on other foods, failed to ensure cleanliness of food serving area and sanitation of food preparation equipment and failed to ensure the dishwasher was operating as designed to sanitize dishes to prevent potential food borne illness to residents. This failure has the potential to affect all 60 residents residing in facility.

Inspectors wroteBased on observation, interview and record review the facility failed to serve foods that were palatable to four (R1, R4, R7, R9) residents out of four residents reviewed for Dietary Services in a sample list of eleven residents.

Inspectors wroteBased on observation, interview and record review the facility failed to serve foods timely based on resident preference to four (R1, R4, R7, R9) residents out of four residents reviewed for Dietary Services in a sample list of eleven residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to protect the resident's right to be free of physical and mental abuse by another resident for one of six residents (R4) reviewed for abuse in a sample of six. This failure caused (R4) to experience psychosocial harm including fear, feeling unsafe, and feeling uncomfortable.