Hilltop Healthcare And Rehabilitation Center

Based on review of clinical records, as well as resident and staff interviews, it was determined that the facility failed to maintain clinical records that were complete and accurately documented for one of 35 residents reviewed (Resident 53).Findings include: An admission Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 53, dated October 9, 2025, revealed that the resident was cognitively intact, and had diagnoses that included diabetes. Physician's orders for Resident 53 dated October included an order for the resident to have blood sugars checked twice a day and if blood sugar is less than 70 mg/dL to follow the hypoglycemia protocol, and if the blood sugars are greater than 400 mg/dL to notify the medical doctor and registered nurse supervisor. Review of the Medication Administration Record (MAR) for Resident 53 for October and November revealed no documented evidence of the blood sugars for the resident from October 6, 2025 at 2000 to November 15, 2025 at 0630. Interview with the Director of Nursing on December 11,…

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 review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies.Findings include: The facility's deficiencies and plan of corrections for an annual survey ending January 17,2025 revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending December 11, 2025, identified repeated deficiencies related to a failure to revise care plans, prepare and store food safely, and ensure infection prevention policies are being followed. The facility's plan of correction for care plan revision, cited during the survey ending January 17, 2025, revealed that the facility would complete audits and report the results of the audits to the QAPI…

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 review of facility policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to ensure that proper infection control practices were followed while administering medications for one of 36 residents reviewed (Resident 30).Findings include: The facility's medication administration policy, dated November 20, 2025, indicated that staff was to follow established facility infection control procedures (e.g., handwashing, antiseptic technique, gloves, isolation precautions, etc.) for the administration of medications as applicable. Physician's orders for Resident 30, dated May 14, 2025 included orders for the resident to receive 10 milligram (mg) of oxycodone (a controlled substance used to treat pain), 250 mg of azithromycin (an antibiotic), 5 mg of prednisone (a steroid), 20 mg of Lasix (a diuretic), 25-250 mg of Sinemet (a medication to treat Parkinson's disease), one puff of 100/6.2/25 micrograms (mcg) Trelegy inhaler, 2- 2.6 mg of senna (a medication to help treat constipation), 20 mg Pepcid (a medication to treat…

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 review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician orders were written and followed for one of six residents reviewed (Resident 2).Findings include:A facility policy for physician's orders, dated July 31, 2025, revealed that verbal orders are given to the nurse by the physician in person or by telephone; however, they are not written by the physician in the medical record. Verbal orders are to be followed through by making appropriate notification.An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 2, dated June 16, 2025, revealed that the resident was understood and could understand others, was cognitively intact and required assistance with daily care needs.A pharmacist recommendation for Resident 2, dated June 18 2025, reviewed and signed by the physician on June 19, 2025, revealed that aspirin and famotidine were to be discontinued.There was no documented evidence in Resident 2's clinical record to…

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 review of policies, as well as observations and staff interviews, it was determined that the facility failed to maintain a clean and sanitary environment in the main kitchen dishroom. Findings include: The facility's policy regarding food preparation and service, dated February 13, 2025, indicated that areas for cleaning dishes and utensils are kept and maintained in a sanitary environment. Observations in the main kitchen dish room on April 1, 2025, at 12:06 p.m. revealed that there was a large, round, upright fan blowing directly on the dish dry rack. The dry rack contained several pots and pans. Those pans were put away and newly cleaned dishes were placed in the dry rack. The fan was noted to have a very heavy amount of visible dirt and debris accumulated on the blade cover. There were several half-inch tendrils of dirt/debris flowing from the fan cover as the fan was blowing toward the clean pots/pans and dishes. Interview with the Dietary Manager on April 1, 2025, at 12:10 p.m. confirmed that a large, upright, dirty fan was blowing directly on the drying rack that…

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 review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that the resident and/or resident representative had an opportunity to formulate an advance directive (instructions regarding the provision of health care when the resident is incapacitated) or assist in formulating an advance directive for six of 54 residents reviewed (Residents 37, 62, 81, 88, 90, 100). Findings include: The facility policy regarding advance directives, dated November 26, 2024, indicated that on admission the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive. The facility will provide the resident or resident representative information, in a manner that is easy to understand, about the right to refuse medical or surgical treatment and formulate an advance directive. Any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team…

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 a review of facility policies and written menus, as well as observations and interviews with residents and staff, it was determined that the facility failed to follow their planned menu. Findings include: A facility policy, dated November 25, 2024, indicated that service staff will inspect food trays to ensure that the correct meal was provided to each resident. Observations on January 13, 2025, at 11:38 a.m. of Resident 100 in her room during lunch revealed that her tray did not have margarine on it for her roll. Interview with the resident at that time revealed that she did not want to eat a dry roll. She stated that she eats in her room and her meal trays routinely come without sugar packets, condiments, napkins, or flatware. Interview with Nurse Aide 4 on January 13, 2025, at 1:09 p.m. confirmed that there was no margarine on any of the trays on A wing, and she called the kitchen, but there was none available. During an interview with a group of residents on January 14, 2025, at 10:26 a.m. the residents indicated that they do not receive the correct menu or they are…

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 review of policies, as well as observations and resident and staff interviews, it was determined that the facility failed to serve palatable food that was at appropriate temperatures. Findings include: The facility's policy regarding food service temperatures, dated November 26, 2024, revealed that meal service temperatures for hot foods were to be 140 degrees Fahrenheit (F) or above, and cold foods were to be 40 degrees F or below. Interview with Resident 77, who was alert and oriented and able to make her needs known, on January 13, 2025, at 12:07 p.m. revealed that she eats in her room, her meal trays were served cold, and foods are overcooked and not palatable. She also does not receive all of the items on her meal ticket. Interview with Resident 100, who was alert and oriented and able to make her needs known, on January 13, 2025, at 11:38 a.m. revealed that she eats in her room and that her meal trays are served cold and without sugar packets, condiments, napkins, or flatware. During an interview with a group of residents on January 14, 2025, at 10:26 a.m. the…

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 review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to store food in accordance with professional standards for food service safety by failing to store food under sanitary conditions, failing to ensure that food was served under sanitary conditions, and failing to ensure that ice was made and stored in sanitary ice machines for one of one ice machines (kitchen). Findings include: The facility's policy regarding food labeling and dating, dated November 26, 2024, revealed that upon receipt, all items must have a received date and an expiration date, and upon opening, all items must have an open date and a use-by date. The facility's policy regarding ice machines and ice storage, dated November 26, 2024, revealed that ice machines and ice storage/distribution containers would be used and maintained to ensure a safe and sanitary supply of ice. The facility's procedure for washing pots and pans, undated, revealed that the staff were to check the chemical sanitizer strength and record the parts per million, 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.

Based on review of established infection control guidelines, facility policy, and residents' clinical records, as well as observations and staff interviews, it was determined that the facility failed to follow infection control guidelines from the Centers for Medicare/Medicaid Services (CMS) and the Centers for Disease Control (CDC) to reduce the spread of infections and prevent cross-contamination for eight of 54 residents reviewed (Residents 7, 8, 11, 12, 34 63, 70, 80). Findings include: CDC guidance on isolation precautions and Implementation of Personal Protective Equipment (PPE) use in Nursing Homes to Prevent Spread of Multidrug-Resistant Organisms (MDRO's - bacteria that have become resistant to certain antibiotics, and these antibiotics can no longer be used to control or kill the bacteria), dated July 12, 2022, indicates that MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce…

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 review of facility policies, as well as observations and staff interviews, it was determined that the facility failed to provide a clean and homelike environment in residents' rooms for one of 54 residents reviewed (Resident 8). Findings include: The facility's policy regarding homelike environment, dated November 26, 2024, indicated that the purpose was to provide a safe, clean, and sanitary living environment for the residents. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 8, dated November 26, 2024, indicated that the resident was cognitively intact, was usually understood and usually able to understand others, was dependent on staff for all care needs, and had diagnoses that included quadriplegia (paralysis or weakness to both side of the body due to brain injury) and depression. Observations of Resident 8's room on January 17, 2025, at 10:39 a.m. revealed that there was an area of broken dry wall, approximately 12 inches by 12 inches near the closet and another area of damaged dry wall that…

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 review of the Resident Assessment Instrument Manual and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that quarterly Minimum Data Set assessments were completed within the required time frame for one of 54 residents reviewed (Resident 81). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2024, indicated that the assessment reference date (ARD - the last day of the assessment's look-back period) of a quarterly MDS assessment must be no more than 92 days after the ARD of the most recent assessment of any type, and the assessment was to have a completion date (Section Z0500B) that was no later than the ARD plus 14 calendar days. A quarterly MDS assessment for Resident 81 had an ARD of December 13, 2024, which was 116 days after the previous annual MDS assessment with an ARD of August 19, 2024. An…

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 review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for two of 54 residents reviewed (Residents 7, 11). Findings include: An annual Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 7, dated December 6, 2024, indicated that the resident was cognitively impaired and required assistance with care needs, was taking an anticoagulant (medication that thins the blood), had an indwelling catheter (a thin, flexible tube inserted into the bladder to drain urine from the bladder), and had diagnoses that included coronary artery disease (a disease that limits blood flow to the heart caused by plaque buildup in the arteries) and neurogenic bladder (bladder lacks control due to nerve or muscle problems). An anticoagulant care plan for Resident 7, dated January 23, 2023, indicated that the resident was on Coumadin (an anticoagulant) therapy related to the presence of a cardiac…

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 clinical record reviews, as well as staff and resident interviews, it was determined that the facility failed to ensure that residents were provided with showers as scheduled for one of 54 residents reviewed (Resident 24). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 24, dated November 4, 2024, indicated that the resident was cognitively intact, was dependent on staff for bathing/showering, and had diagnosis that included chronic congestive heart failure (a long-term condition where the heart cannot pump enough blood to the body) and diabetes. Review of Resident 24's active task list, initiated on July 31, 2024, revealed that the resident had a bathing preference for showers, and showers were scheduled to be provided every Wednesday and Sunday on dayshift. Review of Resident 24's Bath/Shower record, dated October 2024 through December 2024, revealed that a bed bath was provided instead of a shower on October 2, 9, 13, 16, 27, and 30. Only bed baths were provided to the 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 clinical record reviews and staff interviews, it was determined that the facility failed to ensure that physician's orders regarding treatment administration were followed for one of 54 residents reviewed (Resident 9). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 9, dated October 16, 2024, revealed that the resident was cognitively intact, required assistance with personal care needs, and had diagnoses that included Parkinson's Disease (a brain disorder that causes unintended or uncontrollable movements). Physician's orders for Resident 9, dated March 29, 2025, included an order for the resident to receive 2.5 milligrams (mg) of Midodine Hydrochloride (used to treat low blood pressure) twice a day and to hold the medication if the resident's systolic blood pressure (SBP-the top number in a blood pressure reading) is greater than 120. Review of the Medication Administration Record (MAR) for Resident 9, dated October 2024, revealed that 2.5 mg of Midodrine Hydrochloride 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.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that tube feeding residual amounts were documented per the facility's policy for one of 54 residents reviewed (Resident 70). Findings include: The facility's policy regarding checking gastric residual volume (GRV - the amount of fluid remaining in the stomach at a point in time during enteral nutritional feeding), dated November 26, 2024, indicated that the purpose of this procedure is to assess tolerance of enteral feeding and minimize the potential for aspiration. Staff were to aspirate the stomach contents and if the GRV was greater than 250 milliliters (mL), the physician was to be notified, and staff were to asses the resident for feeding intolerance. The person performing the procedure was to record the amount of, if any, gastric residual in the resident's medical record. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 70, dated December 3, 2024, indicated that the…

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 review of the facility's plans of correction and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to correct quality deficiencies and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of corrections for State Survey and Certification (Department of Health) survey ending February 1, 2024, revealed that the facility developed plans of correction that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending January 17, 2025, identified repeated deficiencies related to failure to maintain a homelike environment, failure to maintain accuracy of assessments, failure to update/revise care plans, failure to provide quality of care, failure to ensure food was palatable and had proper serving temperatures, and failed to ensure the food was stored, prepared/served under sanitary…

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 review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure the accountability of controlled medications (drugs with the potential to be abused) for two of four residents reviewed (Residents 3, 4). Findings include: A facility policy for controlled substances, dated August 27, 2024, indicated that the charge nurse on duty maintains the keys to controlled substance containers. Controlled medications are to be wasted or disposed of in the presence of the nurse and a witness who also signs the disposition sheet. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated August 9, 2024, revealed that the resident was cognitively impaired, had pain, and received an opioid (a controlled pain medication). Current physician's orders for Resident 3, included an order for the resident to receive 5 milligrams (mg) of oxycodone every eight hours as needed for pain rated between 5-10 (a numeric scale with 0 representing no pain and 10 representing the…

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 review of policies, as well as observations and staff interviews, it was determined that the facility failed to serve and store food in accordance with professional standards for food service safety by failing to ensure that outdated or expired food was removed from the refrigerator and failing to ensure that dietary staff wore hair coverings that completely covered their hair during food handling. Findings include: Observations in the main cooler on January 29, 2024, at 9:09 a.m. revealed a container of strawberries with a white substance (mold) all over them. Interview with the Dietary Director on January 29, 2024, at 9:09 a.m. confirmed that the strawberries had white mold all over them and then removed them from the cooler. The facility's dietary policy regarding personal hygiene, dated November 30, 2023, revealed that staff members will have their hair off the shoulders, confined in a hair net or cap, and facial hair properly restrained. Observations in the kitchen on February 1, 2024, at 12:21 p.m. revealed dietary staff preparing meal trays for delivery to the units…

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 and staff interviews, it was determined that the facility failed to ensure that the resident environment was maintained in a homelike manner in two of four resident lounge/activity/dining areas (B and C Hall lounge/activity/dining areas). Findings include: Observations in the B Hall resident lounge/activity/dining area on January 29, 2024, at 12:10 p.m. revealed that there were three residents being fed by staff, and there were 10 wheelchairs and two rollators stored in the corner by the windows. Observations on January 30, 2024, at 12:15 p.m. revealed that there were five residents in the dining area eating lunch, and there were six wheelchairs and two rollators stored in the corner by the windows. Interview with Licensed Practical Nurse 1 on January 30, 2024, at 12:30 p.m. confirmed the wheelchairs and rollators were stored in the dining room and the staff did not know where else to store them when not in use. Observations in the C Hall resident lounge/activity/dining area on January 29, 2024, at 12:07 p.m. revealed that there were three residents in the 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 review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate comprehensive Minimum Data Set assessments for nine of 48 residents reviewed (Residents 23, 31, 56, 63, 65, 80, 83, 84, 86). Findings include: The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, revealed that Section O0110K (b) (Hospice Care) was to be coded if hospice services were provided while a resident of the facility and within the last 14 days. Physician's orders for Resident 23, dated August 20, 2021, included an order for the resident to receive hospice Care Services. A current care plan for Resident 23 included a plan of care to provide hospice care to the resident. A quarterly MDS assessment for Resident 23, dated November 30, 2023,…

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 review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized interventions to address resident care needs for four of 48 residents reviewed (Residents 61, 65, 80, 84). Findings include: The facility's policy regarding care plans, dated November 30, 2023, revealed that a comprehensive care plan for each resident will be developed within seven days of completion of the MDS and be individualized to the resident's care needs. A nursing note, dated September 14, 2023, at 1:50 p.m. revealed that Resident 61 was admitted from the hospital and had a pacemaker (a small medical device implanted under the skin that delivers electrical impulses to the heart to help control abnormal heart rhythms) inserted. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 61, dated January 6, 2024, revealed that the resident was cognitively impaired and had a pacemaker. As of February 1, 2024, there…

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 review of facility policies and clinical records, as well as staff interview, it was determined that the facility failed to ensure that residents were assessed and received trauma-informed care to eliminate or mitigate triggers for residents with the diagnosis of Post Traumatic Stress Disorder (PTSD - a mental and behavioral disorder that develops related to a terrifying event) for three of 48 residents reviewed (Residents 65, 80, 84) Findings include: The facility's policy regarding Trauma Informed Care, dated November 30, 2023, revealed the facility will complete an assessment that involves an in-depth process of evaluating the presence of symptoms, their relationship to trauma, as well as the identification of triggers. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 65, dated December 5, 2023, revealed that the resident was was cognitively impaired and had a diagnosis which included Parkinson's disease and Post Traumatic Stress Disorder (PTSD a real disorder that develops when a person has…

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 review of facility policies and observations, as well as resident and staff interviews, it was determined that the facility failed to serve food items at palatable temperatures. Findings include: The facility's policy regarding hot foods, dated November 30, 2023, revealed that dietary staff will serve all hot foods at 135 degrees Fahrenheit (F) or above and ensure that the food is palatable. An interview with a group of residents on January 30, 2024, at 3:30 p.m. revealed that the food served by the facility was sometimes bland and was sometimes served cold. Observations of the lunch meal service in the main kitchen on February 1, 2024, revealed that the C-Wing cart containing a test tray left the main kitchen at 12:36 p.m. and arrived on C-Wing at 12:38 p.m. Trays were passed to the residents that were in their rooms and in the common area at the end of the hall. The last resident was served at 12:56 a.m. The test tray was removed from the cart at 12:56 a.m. and the temperature of the milk was 45.1 degrees F, the coffee was 140 degrees F, the zucchini was 129.3 degrees F,…

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 clinical record reviews and staff interviews, it was determined that the facility failed to ensure that residents' clinical records were complete and accurately documented for one of 48 residents reviewed (Resident 71). Findings include: Physician's orders for Resident 71, dated January 4, 2024, included an order for the resident to receive one 10 milligram (mg) tablet of Midodrine (used to treat low blood pressure) three times per day for hypotension (low blood pressure) and staff was to hold the medication if the systolic blood pressure (the top number of the blood pressure) was greater than 120 millimeters of mercury (mmHg). Medication Administration Records (MAR's) for Resident 71, dated January 2024, revealed that Licensed Practical Nurse 7 documented as administering the 10 mg of Midodrine to the resident on January 12, 2024, at 8:00 a.m. for a blood pressure reading of 138/72 mmHg, and at 1:00 p.m. for a blood pressure reading of 138/78 mmHg; on January 15, 2024, at 1:00 p.m. for a blood pressure reading of 126/62 mmHg; on Janaury 24, 2024, at 1:00 p.m. for a blood…

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 review of the facility's plans of correction for previous surveys, and the results of the current survey, it was determined that the facility's Quality Assurance Performance Improvement (QAPI) committee failed to maintain compliance with nursing home regulations and ensure that plans to improve the delivery of care and services effectively addressed recurring deficiencies. Findings include: The facility's deficiencies and plans of correction for the State Survey and Certification (Department of Health) survey ending February 24, 2023, revealed that the facility developed plans of corrections that included quality assurance systems to ensure that the facility maintained compliance with cited nursing home regulations. The results of the current survey, ending February 1, 2024, identified repeated deficiencies related to a failure to complete Minimum Data Set (MDS) assessments (mandated assessments of residents' abilities and care needs) accurately, to develop comprehensive care plans, following physician's orders, and to prepare and store food under sanitary conditions. The…

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 review of policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that staff followed the facility's policy regarding reporting an allegation of physical abuse in a timely manner for one of 48 residents reviewed (Resident 65). Findings include: The facility's policy regarding abuse, dated November 30, 2023, indicated that employees, facility consultants and/or attending physicians must immediately report any suspected abuse or incidents of abuse to the Director of Nursing. In the absence of the Director of Nursing such reports may be made to the nurse supervisor on duty. Any individual observing an incident of resident abuse or suspecting resident abuse must immediately report such incident to the Nursing Home Administrator, Director of Nursing, or charge nurse. A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 65, dated December 5, 2023, revealed that the resident was was cognitively impaired and had a diagnosis which…

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 clinical record reviews, observations, and staff interviews, it was determined that the facility failed to ensure that a baseline care plan was developed for one of 48 residents reviewed (Resident 94) who was a recent admission. Findings include: A nursing note for Resident 94, dated January 23, 2024, revealed that the resident was admitted from a hospital setting and was alert and oriented to person, place and time. Physician's orders for Resident 94, dated January 23, 2024, included an order for the resident to receive four liters of oxygen via nasal cannula (a tube that is inserted into the nares to delivery oxygen). Observations and an interview with Resident 94 on January 29, 2024, at 12:02 p.m. revealed that the resident was sitting in his wheelchair watching television and was receiving oxygen by nasal canula. The resident was admitted for a short-term stay to receive therapy services. He said he was admitted from the hospital after being in another facility for respite care. The baseline care plan for Resident 94, initiated on January 23, 2024, was incomplete 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.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that a resident's care plan was updated/revised to reflect the resident's specific care needs for two of 48 residents reviewed (Residents 3, 26). Findings include: A significant change Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 3, dated November 16, 2023, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs, and had diagnoses that included high blood pressure and dementia. A care plan, dated January 26, 2023, revealed that the resident and her family preferred that she receive showers twice a week. A review of the December 2023 and January 2024 shower record revealed that the resident was receiving bed baths. A nursing note, dated January 30, 2024, revealed that the nurse spoke with the resident's daughter, and she stated she told staff to bed bath the resident whenever they needed to. An interview with Director of Nursing on January 30, 2024, at…

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 review of clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents received care and treatment in accordance with professional standards of practice by failing to ensure that physician's orders were followed for two of 48 residents reviewed (Residents 23, 83). Findings include: A quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 23, dated November 30, 2023, revealed that the resident was cognitively impaired, was dependent on staff for toileting hygiene, was always incontinent of bowel, and had diagnoses that included dementia. A care plan for Resident 23, dated July 29, 2022, revealed that the resident was to receive incontinent care every two to three hours and as needed. Physician's orders for Resident 23, dated April 2, 2021, included orders for the resident to receive 30 milliliters (ml) of Milk of Magnesia (MOM - an oral laxative) as needed for constipation if no bowel movement by the third day (9 shifts); one Dulcolax suppository (a…

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 review of the Resident Assessment Instrument User's Manual and clinical records, as well as staff interviews, it was determined that the facility failed to complete accurate Minimum Data Set assessments for one of four residents reviewed (Resident 2). Findings include: The Resident Assessment Instrument (RAI) User's Manual, which gives instructions for completing Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, revealed that if a wander/elopement alarm was used, then Section P0200E was to be coded as (0) not used, (1) used less than daily, or (2) used daily. A physician's order and care plan for Resident 2, dated November 2, 2023, included orders for the resident to use a Wanderguard (device that alarms when close to exit doors) and to check the placement/function and skin integrity every shift. The resident's Treatment Administration Record (TAR) for November and December 2023 revealed that the resident used a Wanderguard from November 2 throiugh December 31, 2023. A quarterly MDS assessment for…

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 review of facility policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that residents' clinical records were complete and accurately documented for one of four residents reviewed (Resident 1). Findings include: The facility's policy for Charting and Documentation, dated November 30, 2023, indicated that all services provided to the resident would be documented in the resident's medical record. An admission Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs) for Resident 1, dated January 13, 2024, revealed that the resident was cognitively intact. An interview with Resident 1 on January 25, 2024, at 10:30 a.m. revealed that while she was a resident she was able to leave the building without staff knowing in an attempt to go home. She stated that she observed staff exiting the building and knew just what to do in order to get out the door without it alarming. She then exited the door on the unit and walked around the building until staff found her and returned her to…

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.