Hilltop Health and Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, patternF607Mar 31, 2023

  Based on record review and interviews with the resident and staff, the facility failed to protect residents when contracted Nurse Aide (NA) #1 was allowed to work an entire 12 hour shift providing resident care after Resident #1 reported the NA stuck his finger in her vagina when he was cleaning her from a bowel movement and they failed to implement their abuse policy for reporting when the allegation of sexual abuse was not reported to local law enforcement, and Adult Protective Services (APS) within 2 hours. In addition, the facility failed to notify the state agency of an allegation of sexual abuse within 2 hours. This was for 1 of 3 residents (Resident #1) reviewed for abuse and the deficient practice had the potential to affect other facility residents. […]

• Immediate jeopardy, isolatedF600Mar 31, 2023

  Based on observations, record review, and resident, family, staff, Nurse Practitioner (NP), Medical Director (MD), and Law Enforcement interviews the facility failed to protect residents' rights to be free from sexual abuse for 1 of 3 residents sampled for abuse (Resident #1). The allegation of abuse occurred on 3/22/23 at approximately 5:30 AM when an agency staff member was rough, causing pain to the resident and inserted his finger into the vagina of Resident #1 while performing incontinence care. Resident #1 felt fearful, dirty, humiliated, violated, and borderline raped. The immediate jeopardy began on 3/22/23 when an agency staff member inserted his finger into Resident #1's vagina and was rough during incontinence care causing the resident pain. […]

• Actual harm, isolatedF550Sep 13, 2023

  Based on observation, record review and interviews with the resident and staff, the facility failed to treat a resident in a dignified manner by ensuring a dependent resident could access and activate the call light to request assistance from staff for 1 of 1 resident reviewed for dignity (Resident #122). Resident #122 stated having to yell out for assistance made her feel upset, aggravated and mad. The findings included: Resident #122 was admitted to the facility on [DATE] with diagnoses which included quadriplegia (paralysis of all four limbs) and hemiplegia (paralysis of one side of the body). […]

• Actual harm, isolatedF558Sep 13, 2023

  Based on observation, record review and interviews with the resident and staff, the facility failed provide an adaptive call bell the resident could activate to call for assistance. This resulted in the resident relying on her voice to yell for assistance. This deficient practice occurred for 1 of 1 resident reviewed for accommodation of needs (Resident #122). The findings included: Resident #122 was admitted to the facility on [DATE] with diagnosis which included quadriplegia (paralysis of all four limbs) and hemiplegia (paralysis of one side of the body). An admission Minimum Data Set (MDS) dated [DATE] revealed Resident #122 was moderately cognitively intact and dependent upon two staff members for bed mobility, eating, toilet use, personal hygiene, and bathing. […]

• No harm, potential for more than minimal, patternF679Jan 9, 2025

  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. […]