Hill Top House

The facility had a census of 21 residents. The sample included 12 residents and five nurse aides. Based on observation, record review, and interview, the facility failed to ensure three of the five staff members reviewed possessed the knowledge, skills, and competencies required for resident care needs. This placed the residents at risk of impaired care. Findings included: - Review of the training records and skills check for Certified Nurse Aide (CNA) O, P, and Q lacked evidence of the facility's procedure checklist related to the direct care of the residents. On 11/20/24 at 10:33 AM, Administrative Nurse D stated the facility had conducted a skills check-off the previous summer for the nursing staff, and not all employees attended. Administrative Nurse D stated the facility had not rescheduled or completed any further competencies for staff who did not attend. The facility's undated Required Training of Nurse Aides documented the facility would ensure that nurse aides demonstrate competency in skills and techniques necessary to care for residents as identified through resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility had a census of 21 residents. Based on 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. Findings included: - The PBJ report provided by the Centers for Medicare and Medicaid Service (CMS) for Fiscal Year (YR) 2023 Quarter (Q) 4 indicated the facility did not have licensed nurse coverage 24 hours a day, seven days a week on multiple days (five). A review of the facility's licensed nurse timesheet data for the dates listed on the PBJ revealed a licensed nurse was on duty 24 hours a day seven days a week. On 11/18/24 at 12:26 PM, Administrative Staff A reported the discrepancy may be related to the submission of licensed nurse break hours and this had been adjusted to capture all the hours licensed nurses worked. Administrative Staff D stated the facility had nurse coverage 24 hours a day. The facility's undated Mandatory Submission of Uniform Format Staffing…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility had a census of 21 residents. Based on interviews and record review, the facility failed to implement a water management plan to mitigate risks for Legionella (a bacterium spread through the mist, such as from air-conditioning units for large buildings. Adults over the age of 50 and people with weak immune systems, chronic lung disease, or heavy tobacco use are most at risk of developing pneumonia caused by Legionella). The facility failed to maintain an antibiotic tracking system and did not review its infection control policies annually. This deficient practice placed the 21 residents of the facility at risk for infection. Findings included: - The facility printed out a log that included resident names, locations, and prescriptions. The prescriptions were dated from 9/30/22 to 10/02/24. The log revealed eight prescriptions for antibiotics in 2024 but indicated the infection being treated was unknown. The log lacked documentation of onset, symptoms, or cultures. The facility's Infection Control policy was last reviewed on 07/01/21 and the facility's Vaccine policy was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 21 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to develop a baseline care plan within 48 hours of admission for Resident (R) 123. This placed the resident at risk for impaired care due to unidentified or uncommunicated care needs. Findings included: - R123's Electronic Medical Record (EMR) recorded diagnoses of diabetes mellitus (DM-when the body cannot use glucose, not enough insulin is made, or the body cannot respond to the insulin), urinary incontinence, hypertension (high blood pressure), gastroesophageal reflux disease (GERD-backflow of stomach contents to the esophagus), nutritional deficiencies, anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest), irritable bowel syndrome (IBS- abnormally increased motility of the small and large intestines), a history of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 21 residents. The sample included 12 residents with five reviewed for unnecessary drugs. Based on observation, interview, and record review the facility failed to obtain a stop date from the physician for the use of as-needed (PRN) lorazepam (antianxiety medication) for Resident (R) 9. This placed the resident at risk for complications related to psychotropic (alters mood or thought) medications and unnecessary medication. Findings included: - R9's Electronic Medical Record (EMR) documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), insomnia (inability to sleep), and dementia (a progressive mental disorder characterized by failing memory and confusion) with agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition). The Significant Change Minimum Data Set (MDS), dated…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility had a census of 21 residents. The sample included 12 residents with two reviewed for hospice services. Based on observation, interview, and record review the facility failed to ensure a communication process and collaboration between the hospice provider and the facility for Resident (R) 9 and R17 to coordinate hospice services provided including visit frequency and assessment, medications, and medical equipment. This placed the residents at risk of impaired end-of-life care. Findings included: - R9's Electronic Medical Record (EMR) documented diagnoses of Alzheimer's disease (progressive mental deterioration characterized by confusion and memory failure), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), insomnia (inability to sleep), and dementia (a progressive mental disorder characterized by failing memory and confusion) with agitation (feeling of aggravation or restlessness brought on by a provocation or a medical condition). The Significant…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 24 residents with 12 sampled. Based on interview and record review, the facility failed to review and revise the care plans for one Resident (R)17, regarding new interventions to prevent falls. Findings included: - Review of R17's diagnoses from the Electronic Health Record (EHR) documented repeated falls, weakness, amnesia (a dramatic form of memory loss) and Alzheimer's disease (a progressive dementia - loss of cognitive function such as thinking, remembering and reasoning). Review of R17's annual Minimum Data Set (MDS), dated [DATE], documented a brief interview for mental status (BIMS) of 12, indicating moderately impaired cognition. R17 required extensive assistance of two or more staff with transfers. Review of the Falls Care Area Assessment (CAA) dated 01/02/23, revealed that the resident was at increased risk for falls and injury due to impaired cognition, pain and numbness/weakness to all extremities. The care plan, dated, 02/11/22 revealed: A non-injury fall on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility reported a census of 26 residents. Based on interview and record review the facility failed to address staffing in the Facility Assessment to document resources required to provide necessary care to the residents in regard to staffing across all shifts. This failure had the ability to affect all resident care in the facility. Findings included: - Review of the undated Facility Assessment documented no determination of facility staffing. Interview with Administrative Staff A on 08/02/21 at 01:10 PM revealed the facility assessment did not have a breakdown of how staffing was determined. Administrative Staff A stated she had not completed the facility assessment since last year. Interview with Administrative Nurse B on 08/02/21 at 01:55PM revealed she made the schedule for the nursing staff and the facility determined staffing based on the acuity of the residents. Review of the undated Facility Assessment Policy stated the facility assessment was the foundation to determine staffing levels and competencies to include an evaluation of the overall number of facility staff…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

The facility reported a census of 26 residents. Based on observation, interview, and record review, the facility failed to provide the residents with a way to file a grievances anonymously. Findings included: - During the initial tour of the facility on 07/27/21 at 10:00 AM, there were no grievance forms or a way to submit those forms anonymously noted in the facility. On 07/28/21 at 02:01 PM, Resident (R) 14 stated they did not have forms to fill out for a grievance during the resident council meeting. On 07/28/21 at 02:21 PM, Activity Staff D stated they did not have forms to fill out for grievances, that the residents would tell the staff what the issue was and that the residents could call the Ombudsman with any concerns. On 08/02/21 at 12:12 PM, Activity staff D stated she had not developed a procedure for residents to file an anonymous grievance. On 08/02/21 at 05:00 PM, Administrative Staff A stated she did not know they needed an anonymous way to file a grievance. Review of the facility's undated Complaints or Grievances policy documented that each resident may voice…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 26 residents, with 12 sampled, including one for dignity. Based on observation, interview, and record review, the facility failed to provide quality dignified care for Resident (R) 25 by allowing his fingernails to be overgrown with a dark substance under them after he requested staff trim them. Findings include: - Review of R25's Signed Physician Orders dated 06/15/21 documented the following diagnoses: diabetes mellitus without complications (when the body cannot use glucose, not enough insulin made, or the body cannot respond to the insulin) and major depressive disorder (major mood disorder). Review of the admission Minimal Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) score of five, indicating severely impaired cognition. R25 required the assistance of one staff member for personal hygiene. Review of the ADL Function/ Rehabilitation Potential Care Area Assessment (CAA) dated 07/06/21 documented staff will care plan to maintain the current…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 26 residents, with 12 included in the sample, including one for respiratory care. Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for Resident (R) 12 which included oxygen use and care. Findings Include: - Review of R12's Electronic Health Record (EHR) dated 06/11/21 documented the following diagnoses: schizophrenia (a psychotic disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), chronic obstructive pulmonary disease (COPD, a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), COVID-19, shortness of breath (SOB), and localized edema (swelling resulting from an excessive accumulation of fluid in the body tissues). Review of the Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) of 14,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 26 residents, with 12 sampled, including one for discharge to the community. Based on interview and record review, the facility failed to complete a discharge summary to include the recapitulation of Resident (R) 28's stay. Findings included: - A review of the Minimum Data Set (MDS) documented R28 admitted on [DATE] and discharged on 06/18/21, with no MDS completed. Review of the Electronic Health Records (EHR) Physician Orders documented an order to discharge to Home Care and to follow up with the provider in one week dated 06/18/21. Continued review of the EHR revealed no discharge papers, including a recapitulation of stay, located within R28's record. Interview with Social Services Director (SSD) D on 07/29/21 at 08:20AM stated she did not complete a recapitulation of the stay and that it was the nurses' responsibility to do this. Interview with Administrative Nurse B on 08/02/21 at 11:54 AM confirmed the facility lacked a completed recapitulation of R28's stay. Review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility reported a census of 26 residents, with 12 sampled, including one for respiratory care. Based on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards of practice for Resident (R) 12. - Findings Include: Review of Resident (R) 12's Electronic Health Record (EHR) dated 06/11/21 documented the following diagnoses: Schizophrenia (a psychotic disorder characterized by gross distortion of reality, disturbances of language and communication, and fragmentation of thought), Chronic Obstructive Pulmonary Disease (COPD) - (a progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing), COVID 19, shortness of breath (SOB), and localized edema (swelling resulting from an excessive accumulation of fluid in the body tissues). Review of the Significant Change Minimum Data Set (MDS) dated [DATE] documented a Brief Interview for Mental Status (BIMS) of 14, indicating intact…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.