Hilltop Park Post Acute

In the surveyor’s words

From the most serious findings on record at Hilltop Park Post Acute, in the surveyor’s own words.

• Immediate jeopardy, patternF695Mar 7, 2024

  Based on interviews, observations, and record review, the facility failed to ensure residents received necessary respiratory care and services per professional standards of practice for four (#174, #99, #20, and #95) of four residents reviewed for respiratory care out of 46 sample residents. The facility failed to have an effective system to ensure the residents who required specialized respiratory care received such care in a manner consistent with professional standards of practice. -The facility failed to maintain the necessary respiratory supplies to provide for and manage Resident #174's respiratory needs. Resident #174 had a tracheostomy tube (trach tube) with an inner cannula. He was readmitted from the hospital on 3/3/24 with a supply of 3 inner cannulas. […]

• Immediate jeopardy, isolatedF686Jul 29, 2024

  Based on observations, record review, and interviews, the facility failed to provide one of three residents (#5) out of 21 sample residents, with timely and necessary treatment and services to prevent and manage an avoidable, facility-acquired pressure injury that resulted in the development of a stage 4 coccyx wound with osteomyelitis. Resident #5, who had a diagnosis of paraplegia, was admitted on [DATE] with intact skin. The resident was discovered with an unstageable pressure injury on his coccyx on 11/28/23, 14 days after admission. By 1/2/24, the pressure injury had progressed to a stage 4 pressure injury (full-thickness tissue loss with exposed bone, tendon, or muscle). […]

• Actual harm, isolatedF686Sep 20, 2022

  Based on resident observation, record review, and interviews, the facility failed to ensure residents received care consistent with professional standards of practice to prevent worsening of a pressure injury for one (#1) of three residents with pressure injuries out of 14 sample residents. Resident #1, who required extensive assistance with activities of daily living from staff members for bed mobility, transfers, dressing, and toilet use, was known to be at risk for skin impairment due to her immobility, poor nutrition, and diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF689Feb 24, 2022

  Based on record review and interviews, the facility failed to ensure one (#5) of three residents reviewed for accidents out of seven sample residents remained free from falls and accidents. Specifically, the facility failed to complete a fall risk assessment upon Resident #5's admission to the facility, develop and implement a person-centered care plan that identified the resident's fall risk and put effective interventions into place to reduce falls and prevent injury. Resident #5 fell on [DATE] (six days after her admission to the facility) and sustained a right patellar fracture. […]

• Actual harm, isolatedF686Aug 26, 2021

  Based on observations, record review and interviews the facility failed to prevent the worsening of stage four pressure ulcers for two of two (#3,#42) out of 29 residents reviewed. The facility failed to ensure all interventions were completed and implemented as ordered by Resident #3's physician. Resident #3 who was admitted with a stage 4 pressure ulcer, and was a known high risk for the development and worsening of the already existing pressure ulcer did not have his pressure ulcer interventions implemented consistently to avoid the Stage 4 pressure ulcer from becoming worse. Resident #3's pressure ulcer went from 2.5cm long by 9 cm wide by 0.1 cm deep on 8/19/21 to 5 cm long by 9.5 cm wide by 1.1 cm deep on 8/25/21. […]