Hill Top House

In the surveyor’s words

From the most serious findings on record at Hill Top House, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Apr 21, 2022

  The facility census totaled 21 residents, with three residents reviewed for elopement risk. Based on observation, interview, and record review the facility failed to provide adequate supervision for Resident (R) 1, with a history of exit seeking behaviors (including removing a window screen in October of 2021) and who exited the facility through a window on 04/15/22 at approximately 08:25PM. The facility staff did not know of this until two off duty facility staff members called the facility and reported the resident was at the local convenience store (located six minutes north of the facility and within 500 feet of a major US Highway) and the resident was found scared and tearful. This failure placed R1 in immediate jeopardy. […]

• Actual harm, isolatedF689Feb 15, 2023

  - Observation on 02/14/23 at 09:12 AM revealed Licensed Nurse (LN) G, Certified Medication Aide (CMA) M and Certified Nursing Assistant (CNA) N in the resident's room to provide R 12 morning cares CMA M raised the head of the bed and CNA N assisted her to pivot transfer from the bed. The resident's brief was wet and removed and staff sat the resident on the bedside commode. LN G held the back of the commode. Observation of the commode revealed the leg to the back rest of the commode. LN G held the back so it did not wobble or collapse while the resident used it. The back bar of the commode also had an area of rust approximately 4 inches long across the bar. On 02/14/23 at 09:15 AM, LN G stated she noticed commode lacked a wingnut the day before. […]

• No harm, potential for more than minimal, widespreadF726Nov 20, 2024

  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. […]

• No harm, potential for more than minimal, widespreadF851Nov 20, 2024

  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. […]

• No harm, potential for more than minimal, widespreadF880Nov 20, 2024

  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. […]