Hilltop Center

In the surveyor’s words

From the most serious findings on record at Hilltop Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF610Jun 15, 2022

  Based on record review, resident interview, and staff interviews the facility failed to protect Resident #96 from verbal abuse during an ongoing investigation involving Resident #96 and LPN #83. LPN #83 was allowed into the facility, and she verbally abused Resident #96 in regard to allegations he had previously made against her which were still under investigation. The resident's demeanor and verbalization of being very upset by this incident constitutes immediate jeopardy with psychological harm for Resident #96. The facility was first notified of the Immediate Jeopardy (IJ) at 2:07 PM on 06/14/22. The state agency (SA) provided a revised IJ template at 06/14/22 at 2:49 PM which changed the tag from 600 to 610 which is a more appropriate tag for the situation. […]

• Actual harm, isolatedF600May 13, 2025

  Based on record review and staff interview the facility failed to ensure one (1) of two (2) residents reivewed for pressure ulcers were not neglected. Resident #1 entered the facility without a pressure ulcer. He was discharged to another facility (nursing home). An assessment completed within 40 minutes after his discharge from the facility revealed a deep foul smelling wound to the coccyx. Resident #1 sustained actual harm. Resident identifier: #1. Facility Census: 118 Findings Include: a) Resident #1 Resident #1 was admitted to the facility on [DATE] from a critical illness recovery hospital. He had been at that facility from 01/22/25 - 02/18/25. He had previously been at another acute care hospital from [DATE] - 01/22/25. […]

• Actual harm, isolatedF686May 13, 2025

  Based on record review and staff interview the facility failed to ensure one (1) of two (2) residents reivewed for pressure ulcers received the apprpirate care to treat a wound to the coccyx. Resident #1 entered the facility without a pressure ulcer to the coccyx . He was discharged to another facility (nursing home). An assessment completed within 40 minutes after his discharge from the facility revealed a deep foul smelling wound to the coccyx. Resident #1 sustained actual harm. Resident identifier: #1. Facility Census: 118 Findings Include: a) Resident #1 Resident #1 was admitted to the facility on [DATE] from a critical illness recovery hospital. He had been at that facility from 01/22/25 - 02/18/25. He had previously been at another acute care hospital from [DATE] - 01/22/25. […]

• Actual harm, isolatedF600Jun 15, 2022

  Based on record review, resident interview, and staff interviews the facility failed to ensure all residents were free from abuse and neglect for Resident #96, #2, and #212. Resident #96 was verbally abuse during an ongoing investigation involving Resident #96 and LPN #83. This verbal abuse occurred on 06/10/22 when LPN #83 as was supposed to be suspended from the facility. She entered the facility and verbally abused Resident #96 in regard to the allegations previously made against her by Resident #96. Based on Resident #96's interview it was determined he suffered psychological harm as a result of this incident of verbal abuse from LPN #83. Resident #2 indicated to the survey team they had been abused by LPN #83 on an ongoing basis by having to cry in order to receive her medications. […]

• No harm, potential for more than minimal, widespreadF882Jan 18, 2023

  Based on record review and staff interview, the facility failed to designate a qualified infection preventionist with specialized training in infection prevention and control. This deficient practice had the potential to affect all residents residing in the facility. Facility census: 120. Findings included: a) Infection Preventionist qualifications On 01/17/23 at 2:00 PM, the facility Administrator reported the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were currently acting as the Infection Preventionists. The Administrator was asked to provide evidence of the specialized training in infection prevention and control the DON and ADON had completed. On 01/18/23, no evidence of specialized training in infection prevention and control had been provided. […]