Hilltop Manor Nursing Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689May 12, 2026

  Based on observation, interview, and record review, the facility failed to ensure an environment free from accident hazards for Resident (R) 1. On 03/20/26 at approximately 10:30 AM, Certified Nurse Aide (CNA) M retrieved a lift sling to assist R1 with a full-body mechanical lift. CNA M took the top lift sling from the pile without verifying it was the appropriate sling for R1. CNA M and CNA N then began transferring R1 with a full body mechanical lift using the incorrect sling, which was inadequate for R1's size. The sling had a maximum weight capacity of 150 pounds, and R1 weighed 255 pounds. During the transfer the lift sling ripped at the strap, and the resident fell to the floor, resulting in a left hip and pelvis fracture. This failure placed R1 in immediate jeopardy. […]

• Actual harm, isolatedF689Apr 4, 2024

  The facility had a census of 41 residents. The sample included 12 residents. Based on observation, record review, and interview, the facility failed to identify causal factors for falls, provide adequate supervision, and implement effective interventions to prevent avoidable accidents for Resident R (32) when he had multiple falls over various dates, which resulted in fractures, contusions, increased pain, and multiple trips to the hospital. The facility also failed to identify causal factors and implement interventions to prevent falls for R22. […]

• No harm, potential for more than minimal, widespreadF812Jun 16, 2022

  The facility reported a census of 41 residents, with all receiving meals from one main kitchen. Based on observation, interview, and record review the facility failed to store and serve food in in a sanitary manner when observation revealed undated foods in the kitchen refrigerator and when dietary staff used gloves but cross-contaminated the gloves during food service. Findings included: - On 06/13/22 at 07:58 AM, an initial tour of the kitchen accompanied by Dietary Staff (DS) F revealed a wall of half-size refrigerators with the following food found with no open or use by date: a half-cut onion wrapped in plastic wrap, a bowl of corn relish, a container of baked beans, a bag of cherries undated, a tomato partly cut up, a tub of French Onion dip with no date, a bowl of cut green peppers… […]

• No harm, potential for more than minimal, patternF804Dec 30, 2025

  The facility reported a census of 36 residents. Based on observation, record review, and interview, the facility failed to ensure that meals were served at a safe and appetizing temperature.Findings included:- During an observation on 12/28/25 at 11:33 AM, Dietary CC prepared four servings of pureed fried chicken that had a cooked temperature of 195.6 degrees Fahrenheit (F). Once pureed, the chicken was scraped into a small metal container and placed in the steam table, uncovered. Continued observation at 11:57 AM revealed Dietary Staff CC rechecked the temperature of the pureed chicken in the steam table prior to serving, and the temperature was 132.7 degrees F. The chicken and other food items for this meal were served after all holding temperatures were checked. […]

• No harm, potential for more than minimal, patternF880Dec 30, 2025

  The facility reported a census of 36 residents. The sample included 12 residents. Based on interviews, observation and record review, the facility failed to utilize Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms which employ targeted gown and glove use during high contact care) when providing direct care to a Resident (R) 3 with a feeding tube (tube for introducing high-calorie fluids into the stomach). The facility further failed to ensure adequate hand hygiene before and after personal care for R3, and R23. The facility failed to store nebulizer (a device that changes liquid medication into a mist easily inhaled into the lungs) mask and oxygen nasal cannula in a sanitary manner for R30 and R1. […]