Hilltop Nursing & Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Aug 28, 2025

  Based on record review and interview, the facility failed to ensure a resident's right to be free from neglect by failing to provide the necessary care and services to 1 (Resident #1) of 3 (Resident #1, Resident #2 and Resident #3) sampled residents. Findings:The deficient practice resulted in an Immediate Jeopardy situation for Resident #1 on 07/24/2025 at approximately 2:30 a.m. when Resident #1 was found on the floor by S3 LPN and complained of neck pain. Resident #1 was placed back into bed and S3 LPN failed to notify the Physician of Resident #1's fall and failed to medicate Resident #1 for complaints of pain. Resident #1 sustained a second fall on 07/24/2025 at 4:30 a.m. and then complained of neck, back, and head pain at that time. […]

• Immediate jeopardy, isolatedF658Aug 28, 2025

  Based on record review and interview the facility failed to provide care and services that met professional standards of quality for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled residents, by failing to ensure physician orders were followed timely for the management of pain, and timely hospital transfer after a fall.Findings:The deficient practice resulted in an Immediate Jeopardy situation for Resident #1 on 07/24/2025 at approximately 2:30 a.m. when Resident #1 complained of neck pain after being found on the floor by S3 LPN. S3 LPN failed to notify the physician of the fall and failed to administer pain medications that were ordered and available to give. Resident #1 sustained a second fall on 07/24/2025 at 4:30 a.m. […]

• No harm, potential for more than minimal, widespreadF732Aug 28, 2025

  Based on observation and interview the facility failed to ensure that the nurse staffing pattern was posted daily. The facility census was 89.Findings: Observation on 08/25/2025 at 11:00 a.m. of the posted facility staffing pattern revealed a date of 08/13/2025. Observation and interview on 08/25/2025 at 2:35 p.m. with S2 DON and S10 RN/Charge Nurse stated the [NAME] Clerk had quit abruptly and she was responsible for the daily posting of the facility's staffing pattern. S2 DON confirmed the posted facility staffing sheet was dated 08/13/2025 and did not reflect the current date or staffing, and it should.

• No harm, potential for more than minimal, patternF692Feb 11, 2026

  Based on interview and record review the facility failed to ensure that a resident maintained acceptable parameters of nutritional status for 1 (Resident #11) of 3 residents reviewed for nutrition/weight loss. The facility failed to provide dietary interventions for a resident with significant weight loss. Findings:Review of the undated facility Nutrition/Hydration Management Policy revealed in part .It is the goal of the ID team, with participation by the RD consultant, that residents of this facility maintain acceptable parameters of nutritional status to the extent medically possible. At a minimum, the following residents will be referred to the High Risk committee: Significant weight change (5% or greater in 30 days or less, 10% or greater in 180 days or less). […]

• No harm, potential for more than minimal, patternF812Feb 11, 2026

  Based on observation and interview the facility failed to maintain a clean and sanitary kitchen in accordance with professional standards for food service safety. This deficient practice had the potential to affect all 9 residents who received a puree diet. The facility failed to ensure staff were wearing a beard restraint during meal preparation.Findings:Observation on 02/09/2026 at 11:15 a.m., revealed S13 [NAME] with a hair net on and a full beard/goatee with no beard restraint while preparing the puree recipe for all 9 residents. […]