Hilltop Lodge Health and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, patternF678Jan 9, 2024

  The facility identified a census of 59 residents with 24 residents who elected a full code (term used to indicate the desire to receive resuscitative measures in the event of cardiac arrest) status. Based on record review and interview, the facility failed to ensure staff provided cardiopulmonary resuscitation (CPR) to Resident (R) 1, who desired resuscitative measures as indicated by her full code status. At 11:08 AM on [DATE], staff entered R1's room and identified R1 was not breathing. Staff applied oxygen, but noted R1 had no vital signs at that time. The Registered Nurse on duty, LN G, called the emergency room (ER) at the local hospital and spoke with a physician who LN G referred to as R1's primary care physician (PCP). […]

• Immediate jeopardy, isolatedF689Nov 20, 2024

  The facility identified a census of 69 residents with three residents reviewed for elopements. Based on record review, observation, and interview, the facility failed to identify and implement interventions and failed to provide adequate supervision to prevent an elopement for Resident (R) 1, who was cognitively impaired and at high risk for elopement. On 08/08/24 and 10/28/24 the facility assessed and documented R1 was at high risk for elopement but did not implement any interventions or update R1's plan of care to alert staff regarding R1's elopement risk. On 10/30/24 staff last saw R1 at 07:30 AM. At approximately 10:30 AM, the facility received a phone call from a community member stating an elderly man was walking on the grounds of the facility. […]

• Immediate jeopardy, isolatedF726Nov 21, 2022

  The facility identified a census of 66 residents. Based on record review and interview, the facility failed to ensure licensed nursing staff possessed the skills and knowledge necessary to detect and respond to changes in a resident's condition. On the evening of 10/10/22 at 07:52 PM Resident (R)1 had a blood pressure (BP) of 82/60 millimeters of Mercury (mmHg). R1's clinical record lacked evidence of further assessment and physician notification in response to the abnormally low BP. R1's clinical record lacked evidence licensed nursing staff assessed R1's BP from the abnormal low on 10/10/22 through the morning of 10/15/22. […]

• Immediate jeopardy, isolatedF689Sep 14, 2021

  The facility had a census of 58 residents. The sample included five residents, with three reviewed for wandering and elopement. Based on observation, record review, and interview, the facility failed to ensure a safe and hazard free environment for one of three sampled residents, Resident (R) 1. Cognitively impaired, R1 eloped from the facility through unlocked/unalarmed fire doors on the South hall, entered the unoccupied West hall, opened the West hall exit door, which sounded an alarm in an area that could not be heard by staff, then exited through a door that lead to an area outside of the facility, without staff supervision or knowledge. This deficient practice placed R1 in immediate jeopardy. […]

• Actual harm, isolatedF600May 1, 2023

  The facility identified a census of 62 residents with three residents reviewed for abuse, neglect, and exploitation. The facility failed to provide adequate supervision and failed to implement interventions to prevent an incident of resident to resident abuse from occurring when Resident (R) 2 struck R1 in the face. On 04/24/23 at approximately 12:00 PM, R2 was exiting the dining room and stopped at a table and touched R1 on the shoulder. R2 asked R1 how he was doing. R1 said cursed, and commanded R2 not to touch him. R2 drew his hand back and hit R1 on the right side of the face with enough force to shift R1's body in his wheelchair. R1 and R2 were separated immediately afterwards. Staff escorted R2 back to his room. […]