Hilltop Healthcare Rehabilitation and Skilled Nurs

In the surveyor’s words

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

• Immediate jeopardy, isolatedF678Jan 17, 2025

  Based on interview and document review, the facility failed to follow a Physician Orders for Life-Sustaining Treatment (POLST) to provide cardiopulmonary resuscitation (CPR) for 1 of 3 residents (R1), who wished to have CPR in the event of cardiopulmonary arrest (absence of pulse and respirations). This resulted in an immediate jeopardy (IJ) when R1 was found absent of pulse and respiration, CPR was not initiated and R1 died . The facility implemented immediate corrective action, and was issued at past non-compliance. The IJ began on [DATE] at 8:03 p.m. when licensed practical nurse (LPN)-A found R1 unresponsive in her room and did not initiate CPR per R1's wishes. The administrator and the director of nursing were notified of the IJ on [DATE] at 4:12 p.m. […]

• Immediate jeopardy, isolatedF689Sep 5, 2024

  Based on observation, interview and document review, the facility failed to provide proper supervision during meals to prevent choking for 2 of 3 residents (R1, R2) who required 1:1 supervision during meals. This deficient practice resulted in an immediate jeopardy (IJ) for R1 and R2 when they were not provided 1:1 supervision during meals, and R1 had a coughing episode and R2 fell asleep with food in his mouth. The IJ began on 8/13/24 when R2 was found alone at the dining table sleeping with food in his mouth. The director of nursing (DON) and administrator were notified of the immediate jeopardy at 5:07 p.m. on 9/3/24. […]

• Immediate jeopardy, isolatedF600Aug 19, 2022

  Based on observation, interview and document review, the facility failed to protect 3 of 3 residents (R2, R3, R5) from ongoing resident-to-resident abuse when residents had multiple incidents of abuse and the facility failed to mitigate abuse risks and implement individualized behavioral interventions to prevent future resident-to-resident abuse incidents. This resulted in an immediate jeopardy for R2, R3 and R5. The immediate jeopardy began on 8/15/22 when the facility failed to implement interventions to protect residents from resident-to-resident physical and verbal abuse altercations which was identified on 8/18/22. The administrator and director of nursing were notified of the IJ at 11:17 a.m. on 8/18/22. […]

• Immediate jeopardy, isolatedF689Sep 10, 2021

  Based on interview and document review, the facility failed to ensure adequate supervision in a resident smoking area which resulted in a resident falling asleep while smoking and starting on fire for 1 of 3 residents (R1) reviewed for accidents related to smoking. In addition, the facility also failed to secure assessed resident's smoking materials for 1 of 3 residents (R1). This failure resulted in an immediate jeopardy (IJ) situation when R1 was outside smoking a cigarette, fell asleep and sustained [CONDITION(S)] to both upper legs. In addition, the facility failed to ensure R1's smoking materials were properly stored and secured. The IJ began on 8/29/21, at approximately 1:00 a.m. when R1 fell asleep while smoking and started on fire. […]

• Actual harm, isolatedF689Mar 13, 2025

  Based on observation, interview and document review, the facility failed to ensure care plan interventions were implemented for 1 of 3 resident (R1) reviewed who required the use of a transfer belt during transfers reviewed for falls. R1 sustained actual harm when staff failed to implement the use of a transfer belt during a transfer. R1 fell , fractured multiple ribs, sustained a left sided pneumothorax (free air around lung causing some lung collapse), a left sided hemothorax (blood around the lung cause some lung collapse) that led to chest tube placement, and was sent to the emergency department (ED) requiring medical treatment. […]