Hilltop Skilled NSG & Rehab

In the surveyor’s words

From the most serious findings on record at Hilltop Skilled NSG & Rehab, in the surveyor’s own words.

• Actual harm, isolatedF689May 20, 2025

  Based on interview and record review the facility failed to properly implement fall interventions for one of three (R1) residents reviewed for falls on the sample list of four. This failure resulted in R1 falling and sustaining a left femoral neck fracture. This past noncompliance occurred from 5/1/25 through 5/9/25. Findings Include: The Full QA Report dated 5/1/25 documents R1 had a witnessed fall on 5/1/25 at 12:05 AM. R1 attempted to stand up from her wheelchair and fell to the ground. R1's chair alarm did not sound. R1 displays poor dynamic sitting/standing balance as well as impulsiveness related to her advanced Dementia diagnosis. V4 Certified Nurses Assistant (CNA) was walking by the hallway and observed R1 attempt to stand then lose her balance and fall to the ground. […]

• Actual harm, isolatedF600Jul 19, 2024

  Based on observation, interview and record review the facility failed to protect the resident's right to be free from sexual abuse by another resident and verbal/mental abuse by a staff member for four of seven residents (R1, R2, R3 and R5) reviewed for abuse in the sample list of seven residents. These failures resulted in R2 crying, feeling uncomfortable, and removing herself from shared areas with R1 after R2 was sexually abused by R1 and R5 experiencing feelings of isolation and fear after a staff member verbally/mentally abused R5. Findings include. 1.) R2's Minimum Data Set (MDS) dated [DATE] documents R2 as cognitively intact. This same MDS documents R2 requires staff assistance for transfer into/out of her wheelchair and is able to propel wheelchair independently once seated. […]

• Actual harm, isolatedF610Jul 19, 2024

  Based on observation, interview and record review the facility failed to protect residents (R2, R3) from inappropriate behaviors and sexual abuse by another resident (R1) after an abuse allegation. This failure affects three of seven residents (R2, R3 and R1) reviewed for abuse in the sample list of seven. This failure resulted R2 crying, feeling uncomfortable, and removing herself from shared areas with R1 after R1 was left unsupervised and R1 sexually abused R2. Findings include: The facility policy titled 'Abuse Policy' revised 1/9/24 documents the facility is committed to protecting residents from abuse, neglect, exploitation, misappropriation of property and mistreatment by anyone. […]

• Actual harm, isolatedF689Nov 1, 2023

  Based on observation, interview and record review the facility failed to provide adequate supervision to prevent a resident from leaving the building resulting in a fall outside on the sidewalk (R52) and failed to remove a mechanical lift sling from underneath a resident to prevent sliding in the wheelchair (R18) for two of eight residents (R52, R18) reviewed for accidents in the sample list of 34. This failure resulted in R52 exiting the building unaccompanied and falling resulting in abrasions to R52's face, hand and knee and a bruise to R52's face. Findings include: The facility's Accidents and Incidents policy with a revised date of 9/7/23 documents, Purpose: To provide staff with guidelines for investigating, reporting, and recording Accidents and incidents. […]

• Actual harm, isolatedF600Sep 6, 2023

  Based on observation, interview, and record review the facility failed to protect the resident's right to be free of physical and mental abuse by another resident for one of six residents (R4) reviewed for abuse in a sample of six. This failure caused (R4) to experience psychosocial harm including fear, feeling unsafe, and feeling uncomfortable. Findings include: The facility's abuse prevention policy (not dated) states Resident have the right to be free of abuse, neglect, exploitation, misappropriation of property or mistreatment. This includes but is not limited to corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. […]