Hilltop Health and Rehabilitation

Based on observations, record reviews, and staff interviews, the facility failed to secure insulin injector pens during medication administration, failed to date and label opened insulin injector pens, and failed to remove expired injector pens. This deficient practice was found in 1 of 2 medication carts reviewed for medication storage (Medication Cart #1). The findings included:1. During a continuous observation of the medication administration with Nurse #1 on Medication Cart #1, conducted on 03/09/26 at 4:00 PM through 4:39 PM, four insulin injector pens were left unattended on top of the medication cart. At 4:22 PM, Nurse #1 walked away from the medication cart, into Resident #60's room and out of eyesight of the medication cart with. The four insulin injector pens were left unattended on top of the medication cart. Nurse #1 returned to the medication cart at 4:23 PM. A Resident was sitting beside medication cart waiting for her medication when Nurse #1 walked away. At 4:38 PM, Nurse #1 walked away from the medication cart around the corner and down the hall out of eyesight 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 Based on record review, and staff and Nurse Practitioner interviews, the facility failed to ensure an accurate medical record when medications were ordered by mouth instead of via gastrostomy tube (g-tube) for Resident #4. The facility also failed to accurately document the refusal of Resident #8's compression hose on the Treatment Administration Record (TAR). This was for 2 of 2 residents reviewed for accuracy of the medical record (Resident #4 and Resident #8). Findings included: 1. Resident #4 was initially admitted to the facility on [DATE] with a readmission date of 10/02/24. A review of Resident #4's physician orders revealed an order dated 10/13/24 Diet: NPO-nothing by mouth. An order dated 08/27/25 read: lorazepam (a benzodiazepine medication used for anxiety) 0.5 milligram one (1) tablet by mouth twice daily for anxiety. An order dated 09/26/25 read: sertraline (an antidepressant medication) 100 milligrams by mouth daily for depression. An order dated 11/17/25 read: geri-tussin DM (cough syrup…

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 Based on record review, facility activity calendar, and resident and staff interviews, the facility failed to ensure group activities were planned for outside of the facility to meet the needs of residents who expressed that it was important to them to attend group activities outside of the facility for 7 of 7 residents reviewed for activities (Resident #1, #17, #26, #29, #37, #39 and #58). The residents expressed not being able to leave the facility for over a year made them feel sad, at times lonely or depressed and they missed going out with the group to engage in activities, eat at restaurants, shop and socialize. The findings included: A review of the 2024 and January 2025 activity calendars revealed activities for inside of the facility during the week and on the weekends. There were no activities scheduled for outside of the facility. Observation on 1/06/25 at 10:00 AM revealed the facility was located in a rural area that was within 10-to-15-minute driving distance to numerous local and commercial shops,…

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.

Based on observations, record review and staff interviews, the facility failed to implement their infection control policies and procedures when Nurse #1 failed to wear gloves while performing a capillary blood glucose test for Resident #36. This deficient practice occurred for 1 of 3 staff members observed for infection control practices. The findings included: The facility policy (undated) entitled Personal Protective Equipment read in part: Personal Protective Equipment, or PPE refers to a variety of barriers used alone or in combination to protect skin, from contact with infection agents. It includes gloves. 1. All staff who have contact with residents must wear PPE as appropriate during resident care activities in which exposure to blood is likely. The facility policy (undated) entitled Blood Glucose Monitoring read in part: Procedure: 2. Obtain needed equipment and supplies: Gloves, 3. don gloves. 17. Remove and discard gloves. An observation was completed on 1/7/2025 at 3:33pm of Nurse #1 performing a blood glucose test on Resident #36. After entering Resident #36's room,…

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 Based on record review and interviews with the resident, staff, Consultant Pharmacist, and the Medical Director (MD), The Consultant Pharmacist failed to identify drug irregularities and provide recommendations for 2 of 6 residents reviewed for unnecessary medications (Resident #10 and #40). The findings included: 1. Resident #10 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus (DM). The care plan initiated on 04/28/23 indicated Resident #10 was at risk of fluctuating blood sugars due to diabetes. The goal was to remain free of complications related to diabetes through the next review date. Intervention included to administer medications as ordered. The significant change in status Minimum Data Set (MDS) assessment dated [DATE] coded Resident #10 with intact cognition and indicated he was receiving insulin daily during the 7-day assessment period. Review of physician's orders dated 07/05/23 revealed Resident #10 had an order to receive 10 units of Novolog insulin…

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 Based on record review and interviews with the resident, staff, Consultant Pharmacist, and the Medical Director (MD), the facility failed to prevent significant medication errors when nurses failed to follow the physician's parameter as ordered during insulin administration. As a result, Resident #10 had received 19 doses of unnecessary Novolog insulin within 69 days, and Resident #40 had missed 14 doses of Humalog insulin within 73 days. This affected 2 of 6 residents reviewed for unnecessary medications (Resident #10 and #40). The findings included: 1.Resident #10 was admitted to the facility on [DATE] with diagnoses included diabetes mellitus (DM). The care plan initiated on 04/28/23 indicated Resident #10 was at risk of fluctuating blood sugars due to diabetes. The goal was to remain free of complications related to diabetes through the next review date. Intervention included to administer medications as ordered. The significant change in status Minimum Data Set (MDS) assessment dated [DATE] coded 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.

Based on observation, staff interviews, and record reviews, the facility failed to remove expired over the counter (OTC) medications in accordance with the manufacturer's expiration date for 1 or 2 medication rooms observed during medication storage checks (Medication Room B). The findings included: A medication storage audit was conducted on 09/12/23 at 5:45 PM for Medication Room B in the presence of the Unit Manager (UM). The following expired medications were found in Medication Room B and ready to be used: a. 9 unopened bottles of Senna syrup expired on 07/31/22. Each bottle contained 237 milliliters (ml) of syrup. b. 1 opened bottle contained 100 tablets of Calcium 600 milligrams (mg) with Vitamin D3 expired on 10/31/22. c. 5 unopened bottles of Geri-Lanta antacid suspension expired on 06/30/23. Each bottle contained 335 ml of suspension. During an interview conducted on 09/12/23 at 5:51 PM, the UM acknowledged that the above medications had expired and needed to be discarded. She stated the central supply clerk was responsible to check and rotate the OTC medications 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.

Based on observations, record review and staff interviews, the facility failed to remove expired food items in 2 of 2 nourishment rooms. These practices had the potential to affect food served to residents. Findings included: An observation and interview conducted with Nurse Aide (NA) #3 in nourishment room on hall 200 on 09/11/23 at 11:00 AM revealed two fat free milk cartons with expiration date of 09/09/23, pimento cheese sandwich with discard date 08/20/23, and tuna sandwich with discard date 09/10/23. NA #3 further revealed staff had been educated to throw away expired food and drinks and should have been thrown away already. An observation and interview conducted with Nurse #4 in nourishment room on hall 100 on 09/11/23 at 11:15 AM revealed a tuna salad sandwich with discard date 08/29/23. Nurse #4 further revealed dietary was responsible for checking nourishment rooms daily, but nursing staff was also educated to throw away expired food and drinks. Nurse #4 indicated the expired sandwich should have already been discarded. An interview conducted with Dietary Manager (DM) 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.

Based on observations, record review and staff interviews, the facility's Quality Assessment and Assurance (QAA) Committee failed to maintain implemented procedures and monitor interventions previously put in place following the recertification survey of 4/27/2022. The repeat deficiency was cited on the current recertification survey of 9/13/2023 in the area of Infection Control (F880). The facility's continued failure during two Federal Surveys showed a pattern of the facility's inability to sustain an effective QAA program. The findings included: F-880: Based on record review, observations and staff interviews, the facility failed to implement their infection control policies for Covid-19 when Nurse #5 failed to change into full Personal Protective Equipment (PPE), to include changing out of her surgical mask and applying a N95 mask, prior to entering a room that was on enhanced droplet precautions for Covid-19. This observation occurred during an active outbreak of Covid-19 for 1 of 2 rooms on enhanced droplet precautions for positive Covid-19. During the recertification and…

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 Based on record review, observations and staff interviews, the facility failed to implement their infection control policies for Covid-19 when Nurse #5 failed to change into full Personal Protective Equipment (PPE), to include changing out of her surgical mask and applying a N95 mask, prior to entering a room that was on enhanced droplet precautions for Covid-19. This observation occurred during an active outbreak of Covid-19 for 1of 2 resident rooms on enhanced droplet precautions for positive Covid-19. The findings included: The facility's policy entitled Covid-19 Prevention, Response and Reporting implemented 5/15/2023 and revised on 8/5/2023 indicated under #9 Source control measures: Source control options for HCP include: A NIOSH-approved particulate respirator with N95 filters or higher. A respirator approved under standards used in other countries that are like NIOSH-approved N95 filtering facepiece respirators. A barrier face covering that meets ASTM F302-21 requirements including Workplace Performance…

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.