Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hilltop Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Failure to Address Significant Weight Loss: A resident with stroke-related deficits, vitamin deficiency, and muscle wasting had repeated significant weight loss while on weekly weights and identified as high risk for malnutrition. The chart showed no documented dietary interventions despite the loss, and the DON confirmed the resident’s weight loss was significant but not addressed before hospitalization; the RD stated she was not notified until after she first saw the resident and then made new recommendations.
Missing Beard Restraint During Puree Meal Preparation: A dietary staff member with a full beard/goatee was observed preparing puree meals for 9 residents while wearing a hair net but no beard restraint. The Dietary Manager later confirmed the beard restraint was missing and should have been worn during meal prep.
Inadequate Supply of Clean Towels and Washcloths: Residents reported not having enough towels or washcloths available in hall linen storage for personal hygiene. Observations found multiple halls with few or none of these items, and CNAs said this had been an ongoing issue, requiring them to search the facility for supplies needed for peri- and ADL care. An Assistant Admin confirmed the shortage affected all residents.
A facility failed to ensure residents received mail on Saturdays, despite resident rights stating mail should be promptly received unopened. During a Resident Council meeting, residents said weekend mail was not delivered until Monday, and the SSD confirmed weekend mail was held until Monday for sorting. The Weekend Activity Director stated she had never been trained or instructed to handle resident mail on Saturdays and confirmed mail had not been delivered on Saturdays since her hire.
A resident at high risk for malnutrition had weekly weights showing significant weight loss, but the DON did not notify the MD or RD as required by the care plan. The resident had diagnoses including CVA-related hemiplegia, vitamin deficiency, and muscle wasting, required set-up assistance with eating, and the RD stated she was not informed of the weight loss until later, when new recommendations were made.
Failure to reposition a resident as ordered. A resident with Parkinson's disease, moderate cognitive impairment, and multiple other diagnoses had a care plan for turning and repositioning every 2 hours and as needed while in bed or chair. Observations showed CNAs entered the room to reposition the resident, but the resident was later found not to have been repositioned every 2 hours and remained on his back side. A CNA acknowledged the missed repositioning, and the DON confirmed the resident should have been turned and repositioned but was not.
A resident identified as an unsafe smoker was observed smoking without staff supervision despite physician orders, a smoking safety assessment, and the care plan requiring 1 cigarette at a time with staff supervision in designated smoking areas. Staff wheeled the resident to the smoking area, lit the cigarette, and walked away, and later observations again showed the resident smoking unsupervised; the Charge RN and DON confirmed the resident should have been supervised.
Pureed Diets Not Followed for Multiple Residents: Three residents with physician-ordered pureed diets were observed receiving breakfast trays that included ground sausage or ground meat instead of pureed food. Meal tickets reflected the pureed orders, and the dietary manager confirmed that one resident ordered pureed received ground meat and acknowledged the same issue for the other two residents.
Improper Storage of Clean Linens and Equipment: Staff were observed drying and storing lift slings, a privacy curtain, and a geri-chair cushion on a metal rack outside the laundry room, piled together and exposed to outside air and elements. A privacy curtain was seen touching the concrete with debris on it, and the LNA/Laundry staff and Laundry Supervisor confirmed the items should have been clean but were not.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not ensure that the services provided met professional standards of quality, as identified by surveyors through observation and review of facility practices.
The facility did not post up-to-date nurse staffing information, as the displayed staffing sheet was outdated and did not reflect current staffing. The DON and an RN/Charge Nurse confirmed that the staff member responsible for posting this information had quit abruptly, leading to the deficiency.
The facility failed to provide quarterly personal funds statements to three residents, despite holding funds for 52 residents. The residents had authorized the facility to manage their funds and elected to receive statements, but interviews confirmed they never received them. Staff admitted there was no system in place to ensure the distribution of these statements.
The facility did not hold quarterly Quality Assessment and Assurance (QAA) meetings as required, with the last meeting occurring several months ago. The Director of Nursing confirmed that no meetings had been conducted since, and the Medical Director had not reviewed current QAPI data.
A resident was found self-administering Afrin nasal spray without a proper assessment, physician's order, or care plan. The facility's policy requires an interdisciplinary team assessment and specific order for self-administration, which were not in place. Staff confirmed the absence of necessary documentation and approval for the resident's self-administration of the nasal spray.
A facility failed to ensure a resident's call light was accessible, as required by policy. The resident, with severe cognitive impairment and significant physical assistance needs, had their call light positioned out of reach at the foot of the bed. Observations confirmed the call light was not visible or accessible, and staff acknowledged it should have been within reach.
The facility failed to report serious injuries of three residents to the State Survey Agency within the required timeframe. A resident with severe cognitive impairment sustained an avulsion fracture, another had an un-witnessed fall resulting in a femur fracture, and a third resident was found to have a compression fracture. Despite being aware of these injuries, the facility did not report them as mandated by state law.
A facility failed to complete required discharge documentation for a resident with multiple diagnoses, including anxiety disorders and diabetes. The resident's medical record lacked a discharge summary, physician order, and necessary information for the receiving provider. Interviews confirmed the absence of documentation, despite the Administrator's involvement in the transfer.
A resident with severe cognitive impairment and a right hand contracture did not have a required hand roll in place, as observed over several days. Despite care plan and physician orders specifying the use of a hand roll, staff were unable to locate it, indicating a failure to implement the resident's care plan.
The facility failed to update care plans for two residents, one requiring oxygen therapy and another self-administering medications. A resident adjusted her oxygen concentrator against physician orders, and another resident self-administered nasal spray without a care plan or order. Staff confirmed the care plans were not updated to reflect these needs.
The facility failed to document discharge summaries for two residents, one with multiple diagnoses including Alzheimer's and another with moderate cognitive impairment. Both residents were discharged without the necessary documentation, as confirmed by interviews with facility staff.
The facility did not complete annual performance reviews for two CNAs as required by policy. The DON, responsible for conducting and signing off on these evaluations, confirmed that they had not been completed. Personnel records lacked evidence of evaluations for CNAs hired over a year ago.
Failure to Address Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable nutritional status by not providing dietary interventions for significant weight loss. The resident was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, deficiency of other vitamins, and muscle wasting. The resident’s orders included weekly weights and identified the resident as high risk of malnutrition related to GERD, hyperlipidemia, hypertension, anxiety, pain, and hypothyroidism. The admission MDS showed a BIMS score of 14 and that the resident required set-up assistance with eating. The resident’s weight record showed repeated significant losses, including a drop from 108.0 lbs to 100.0 lbs and other measurements reflecting a 5% or greater loss over 30 days. The significant change MDS documented weight loss of 5% or more in the last month and that the resident was not on a prescribed weight loss regimen. The care plan identified the resident as high risk for malnutrition and dehydration and included weekly weights and reporting significant weight loss to the MD/NP, but the record contained no evidence of dietary interventions to address the weight loss. The DON stated she was responsible for entering weights and said she would notify the physician and RD when a weight loss triggered, but confirmed there was no documentation of dietary interventions before the resident’s hospitalization. The RD stated she had not been notified of the significant weight loss and first saw the resident after the hospitalization, when new recommendations were made.
Missing Beard Restraint During Puree Meal Preparation
Penalty
Summary
The facility failed to maintain a clean and sanitary kitchen in accordance with professional standards for food service safety. During observation on 02/09/2026 at 11:15 a.m., S13 was seen wearing a hair net but no beard restraint while preparing the puree recipe for all 9 residents who received a puree diet. S13 stated that he always prepared the puree meals for the residents in the facility. During an interview later that day at 12:45 p.m., the Dietary Manager confirmed that S13 did not have a beard restraint net to cover his beard during puree meal preparation and should have.
Inadequate Supply of Clean Towels and Washcloths
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents and staff by not maintaining an adequate supply of clean towels and washcloths in the hall linen storage areas. During the Resident Council Meeting, two residents expressed concerns about not having enough towels or washcloths available to properly clean and dry themselves. Observation of the linen closets showed that Hall X had six towels and no washcloths, Hall V had no towels and four washcloths, Hall W had one towel and four washcloths, and later Hall V had no towels or washcloths, Hall W had no towels and one washcloth, Hall X had six towels and one washcloth, and Hall Z had no towels or washcloths. Interviews with laundry staff revealed that linens, towels, and washcloths were delivered to the halls in the morning and picked up during the evening shift, but after 11:00 p.m. there was no laundry service until morning workers arrived. CNAs reported that the lack of towels and washcloths had been an ongoing issue and that they had to search the facility to find them. One CNA stated that there were no towels or washcloths available upon arrival for resident care, and laundry staff confirmed that towels and washcloths were used for peri- and ADL care. An Assistant Admin confirmed there was an inadequate number of towels and washcloths for all residents in the facility.
Failure to Deliver Resident Mail on Saturdays
Penalty
Summary
The facility failed to ensure residents received mail on Saturdays, despite the resident rights admission packet stating that residents have the right to send and promptly receive unopened mail. During the Resident Council meeting, residents stated they did not receive mail on Saturdays and wanted personal mail delivered the same day it arrived at the facility. The S5 SSD stated that weekend mail was not given to residents on Saturdays and was instead received on Monday mornings for sorting and distribution. In an interview, the S2 Assistant Admin stated the Weekend Activity Director should distribute resident mail on Saturdays when it is received and not wait until Monday morning. The S6 Weekend SSD stated she had worked as the Weekend Activity Director since 03/2024 and had never been trained or instructed to procure, sort, or deliver mail to residents on Saturdays, and confirmed that no mail had been delivered to residents on Saturday since her hiring.
Failure to Notify Physician and RD of Significant Weight Loss
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan with measurable objectives and timeframes for a resident identified as high risk for malnutrition. The resident was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, deficiency of other vitamins, and muscle wasting. The resident’s admission MDS showed a BIMS score of 14, indicating intact cognition, and the resident required set-up assistance with eating. The physician orders included weekly weights and identified the resident as high risk of malnutrition related to GERD, hyperlipidemia, hypertension, anxiety, pain, and hypothyroidism. The resident’s weekly weights showed a decline from 108.0 pounds to 101.8 pounds, with documentation reflecting significant weight loss of 5% or more over 30 days and 7.5% over a comparison period. The care plan addressed high risk for malnutrition and dehydration and included weekly weights and reporting significant weight loss to the MD/NP, but the DON stated the physician and RD were not notified of the significant weight loss. The DON confirmed that if it was not charted, the physician or RD was not notified, and the RD stated she was not notified of the weight loss and first saw the resident later, when she made new recommendations.
Failure to Reposition Resident as Ordered
Penalty
Summary
The facility failed to ensure a resident who was unable to carry out ADLs received the ordered services to maintain bed mobility. Resident #5 had diagnoses including Parkinson's disease without dyskinesia, persistent atrial fibrillation, bipolar disorder, generalized anxiety disorder, depressive disorder, alcohol abuse, and hypotension. The resident's quarterly MDS showed a BIMS of 9, indicating moderate cognition, and the care plan included an intervention for turning and repositioning every 2 hours and as needed while in bed or chair. The facility policy also stated that residents unable to move in bed without assistance should be changed at least every 2 hours. An observation showed an over-bed sign in Resident #5's room directing repositioning at specific intervals and positions. During an observation, two CNAs entered the room to reposition the resident, then exited. Later observation showed the resident was not repositioned every 2 hours and remained on his back side during the observed period. One CNA stated the resident required repositioning every 2 hours and acknowledged she did not reposition him every 2 hours but should have. The DON confirmed staff were to reposition residents every 2 hours and confirmed Resident #5 should have been turned and repositioned but was not.
Unsafe Smoker Left Unsupervised While Smoking
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision to prevent incidents and accidents when smoking. Resident #34 was admitted to the facility on 06/06/2011 and had diagnoses including Primary Generalized Osteoarthritis, Lack of Coordination, Anxiety Disorder, and Drug Induced Subacute Dyskinesia. Her quarterly MDS with an ARD of 01/09/2026 showed a BIMS score of 12 and that she was a current tobacco user. Her physician orders for 02/2026 stated that she was an unsafe smoker and was to receive only 1 cigarette at a time at designated smoke times in designated areas with staff supervision. The smoking safety assessment and care plan also identified Resident #34 as an unsafe smoker and directed that she receive 1 cigarette at a time with staff supervision. Despite this, observation on 02/09/2026 showed a staff member wheeling her to the designated smoking area, giving her one cigarette, lighting it, and walking away while she smoked unsupervised. Additional observations on 02/09/2026 and 02/10/2026 showed her sitting in the designated smoking area smoking without supervision. The Charge RN stated that she was an unsafe smoker, and the DON confirmed that she should have been supervised while smoking but was not.
Pureed Diets Not Followed for Multiple Residents
Penalty
Summary
The facility failed to ensure that residents received mechanically altered diets as ordered by the physician for 3 reviewed residents (#4, #49, and #50). Resident #4 had diagnoses including generalized anxiety disorder, essential hypertension, chronic embolism and thrombosis of other specified veins, and localized edema, and his record showed an order for a regular NSOT diet with pureed texture and regular/thin liquids. During breakfast observation, Resident #4 was served scrambled eggs and ground sausage, which were not pureed as ordered, and the meal ticket also reflected a pureed diet. Resident #49 had diagnoses including atherosclerotic heart disease, hypertension, congestive heart failure, and severe protein calorie malnutrition, and was ordered a regular diet with pureed texture and regular/thin liquids. On two separate breakfast observations, Resident #49’s meal ticket showed a pureed diet, but the tray contained sausage that was ground in texture rather than pureed. Resident #50 had diagnoses including diffuse traumatic brain injury, nutritional deficiencies, hypertension, COPD, dysphagia following other cerebrovascular disease, and cognitive communication disorder, and was ordered a regular diet with pureed texture and nectar/mildly thick liquids. During breakfast observation, Resident #50’s tray also contained sausage that was ground in texture rather than pureed as ordered. The dietary manager confirmed that Resident #49 was ordered a pureed diet but received ground meat, and acknowledged that Residents #4 and #50, who were ordered pureed diets, also received ground meat.
Improper Storage of Clean Linens and Equipment
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment. Observations on 02/10/2026 and 02/11/2026 showed lift slings and a privacy curtain draped on a metal rack outside the laundry room door, piled on top of each other and left open to outside air and elements. During an interview, S9 Laundry stated this was how lift slings and privacy curtains were dried and stored because the laundry had nowhere else to dry or store large items. On 02/11/2026, another observation of the same area showed a metal hanging rack with 6 lift slings, 1 privacy curtain, and a geri-chair cushion piled on top of each other and draped over the rack. The privacy curtain was hanging down and touching the concrete, with debris on it. S9 Laundry confirmed the curtain should not have been touching the concrete. S16 Laundry Supervisor also confirmed the findings, stating CNAs remove the slings from the lifts at night, take them to the laundry to be washed, and hang them on the metal rack to dry until CNAs pick them up in the morning. S16 Laundry Supervisor removed the curtain and observed debris and rust marks where it had contacted the metal rack, and confirmed the lift slings, privacy curtain, and geri-chair pad should have been clean but were not.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report documents that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Meet Professional Standards of Quality
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality. This deficiency was identified through surveyor observation and review of facility practices, indicating that the care delivered did not consistently adhere to established professional guidelines. Specific details regarding the actions or omissions leading to this deficiency, as well as information about the residents or staff involved, were not provided in the report.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the daily nurse staffing pattern was posted as required. On observation, the posted staffing information was found to be outdated, displaying a date from nearly two weeks prior. During interviews, the Director of Nursing (DON) and an RN/Charge Nurse confirmed that the staff member responsible for posting the daily staffing pattern had quit abruptly, resulting in the failure to update and post current staffing information. The posted sheet did not reflect the current date or actual staffing for the day of the survey, despite a facility census of 89 residents.
Failure to Provide Quarterly Personal Funds Statements
Penalty
Summary
The facility failed to provide quarterly personal funds statements to three residents, despite holding personal funds for a total of 52 residents. The facility's policy, as outlined in the Admission Packet dated February 2023, mandates that individual financial records must be available through quarterly statements and upon request to the resident or their legal representative. However, interviews and record reviews revealed that Residents #44, #67, and #75, who had authorized the facility to manage their funds and elected to receive quarterly statements, did not receive them. Interviews with the residents confirmed that they had never received the required quarterly statements and expressed a desire to receive them. Further interviews with facility staff, including S9 HR and S14 BOM, confirmed the absence of a system to ensure the distribution of these statements. The staff acknowledged that no quarterly statements were provided to any of the 52 residents whose funds were managed by the facility, indicating a systemic issue in the facility's financial management practices.
Failure to Conduct Quarterly QAA Meetings
Penalty
Summary
The facility failed to ensure that the Quality Assessment and Assurance (QAA) committee met at least quarterly and included the required staff members. The facility's policy on Quality Assurance and Performance Improvement (QAPI) guidelines mandates that the committee should identify issues affecting the quality of care and services provided to residents, with the Medical Director and consultants included in quarterly meetings. However, a review of the facility's QAA committee sign-in sheets revealed that the last meeting was conducted on July 11, 2023. An interview with the Director of Nursing (DON) confirmed that no quarterly QAA meetings had been conducted since that date, and neither the Medical Director nor any governing body member had reviewed current QAPI data since the last meeting.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that the interdisciplinary team assessed and determined if a resident was clinically appropriate for self-administration of medication. Specifically, Resident #75 was found to be self-administering Afrin nasal spray without a proper assessment, physician's order, or care plan in place. The facility's policy requires that the interdisciplinary team assess a resident's ability to safely self-administer medications and obtain a specific order if the right is granted. However, Resident #75's clinical record lacked a self-administration assessment for the Afrin nasal spray, and there was no care plan reflecting self-administration. Observations and interviews revealed that Resident #75 had Afrin nasal spray and eye drops at his bedside, which he was self-administering. Interviews with facility staff, including LPNs and RNs, confirmed that there was no self-administration assessment or physician's order for the Afrin nasal spray. The Director of Nursing and another RN also confirmed the absence of a care plan or order for self-administration, acknowledging that the nasal spray should not have been in the resident's room without proper documentation and approval.
Failure to Provide Accessible Call Light for Resident
Penalty
Summary
The facility failed to ensure reasonable accommodation of needs for a resident by not providing an accessible call light. The facility's policy requires that each resident have the call light within reach at all times, regardless of their ability to use it. However, observations revealed that the call light for a resident with severe cognitive impairment and significant physical assistance needs was not within reach. The resident, who required extensive assistance with bed mobility and was totally dependent on staff for transfers, had their call light positioned at the foot of the bed, out of reach. Further observations confirmed that the call light was not visible or accessible to the resident, as it was found behind the bed near the foot. Staff members, including an LPN and a CNA, confirmed during an interview that the call light was not within reach and acknowledged that it should have been. The resident's care plan specifically noted the need to keep the call light in reach and respond in a timely manner, highlighting the facility's failure to adhere to its own policies and the resident's care plan requirements.
Failure to Report Resident Injuries Timely
Penalty
Summary
The facility failed to report serious bodily injuries of three residents to the State Survey Agency within the required two-hour timeframe, as mandated by state law. Resident #42, who had severe cognitive impairment and required extensive assistance, sustained an avulsion fracture of the medial femoral condyle. The injury was discovered following an x-ray ordered by a nurse practitioner to rule out osteomyelitis. Despite the facility's awareness of the injury on the day it was discovered, the incident was not reported to the State Survey Agency as required. Resident #93, also with severe cognitive impairment, experienced an un-witnessed fall resulting in a right femur neck fracture with impaction. Initially, x-rays did not reveal any fractures, but subsequent imaging confirmed the injury. The facility was aware of the fracture on the day it was confirmed, yet failed to report it to the State Survey Agency. The resident's fall and subsequent injury were not witnessed, and the resident was known to be at high risk for falls. Resident #96, with moderate cognitive impairment, was found to have a compression fracture of L1 following an MRI. The facility became aware of this major injury of unknown origin on the day the MRI results were received. However, the required report to the State Survey Agency was not initiated. The facility's policy mandates immediate reporting of such incidents, but this protocol was not followed for any of the three residents, resulting in a deficiency.
Failure to Complete Required Discharge Documentation
Penalty
Summary
The facility failed to ensure that required discharge documentation was completed for a resident who was reviewed for discharge. The facility's policy on discharge planning emphasizes the importance of a planned program of continuing care to meet each resident's discharge needs. However, the facility did not adhere to its policy, as evidenced by the lack of a completed discharge summary and other necessary documentation in the resident's medical record. This includes the absence of a physician order for discharge, the basis for the discharge, and information provided to the receiving provider, such as contact information, advance directive information, and comprehensive care plan goals. The resident in question had multiple diagnoses, including anxiety disorders, diabetes mellitus, cerebral infarction, aphasia following cerebral infarction, depressive episodes, chronic pain, and chronic obstructive pulmonary disease. The resident's Minimum Data Set (MDS) indicated moderate cognitive impairment. Interviews with the Director of Nursing (DON) and the Administrator confirmed the absence of the required discharge documentation in the resident's medical record, despite the Administrator's involvement in the resident's transfer to another facility.
Failure to Implement Care Plan for Resident's Hand Contracture
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident with severe cognitive impairment and multiple medical conditions, including contracture of the right hand. The resident required a hand roll to manage the contracture, as indicated in their care plan and physician orders. However, observations over several days revealed that the hand roll was not in use, and staff were unable to locate it in the resident's room. Interviews with an LPN and a CNA confirmed that the resident was supposed to use a hand roll for the contracted hand, but it was not in place during the observations. The staff acknowledged the absence of the hand roll, which was a necessary intervention for the resident's condition, as outlined in the care plan and medical orders. This oversight indicates a failure to adhere to the established care plan and physician directives for the resident's care.
Failure to Update Care Plans for Oxygen Therapy and Self-Administration of Medications
Penalty
Summary
The facility failed to ensure a comprehensive person-centered care plan was reviewed and revised for two residents. For one resident, who required oxygen therapy due to COPD and other conditions, the care plan did not include education for the resident to notify nursing staff if there was a need to increase her oxygen. Observations revealed that the resident was adjusting her oxygen concentrator to 3 liters/minute, contrary to the physician's order of 2 liters/minute. Interviews with staff confirmed that the resident was not care planned to adjust her oxygen level and that the care plan should have been updated to include this information. Another resident, who was cognitively intact and had a history of restlessness and agitation, was found to have nasal sprays and eye drops in his room for self-administration. However, the care plan did not include an order for self-administration of the nasal spray, and there was no self-administration assessment in the resident's medical record. Interviews with staff confirmed that the resident should not have been self-administering the nasal spray at bedside without a proper order and care plan. The deficiencies highlight the facility's failure to update and revise care plans to reflect the residents' current needs and physician orders. This oversight resulted in residents managing their medications and treatments without appropriate guidance and documentation, which could potentially impact their health and safety.
Failure to Document Discharge Summaries for Two Residents
Penalty
Summary
The facility failed to document a discharge summary for two residents, leading to a deficiency in communication of necessary information at the time of discharge. Resident #98, who had multiple diagnoses including Type 2 Diabetes Mellitus with foot ulcer and Alzheimer's Disease, was transferred to a behavioral health hospital due to behaviors and safety concerns. Despite being discharged from the behavioral hospital to another facility, no discharge summary was completed. Interviews with the social worker, Director of Nursing (DON), Assistant Administrator, and Administrator confirmed the absence of a discharge summary for Resident #98. Similarly, Resident #99, who had diagnoses including Anxiety Disorders, Diabetes Mellitus, and Chronic Obstructive Pulmonary Disease, was discharged without a documented discharge summary. The resident had a Brief Interview for Mental Status (BIMS) score indicating moderate cognitive impairment. The DON and Administrator confirmed that a discharge summary should have been completed but was not present in the resident's medical record. This lack of documentation for both residents indicates a failure in the facility's discharge process.
Failure to Conduct Annual CNA Performance Reviews
Penalty
Summary
The facility failed to conduct annual performance reviews for certified nurse aides (CNAs) as required by their policy. Specifically, the personnel records for two CNAs, hired on 12/01/2022 and 08/19/2021, lacked evidence of completed and signed annual performance evaluations within the past 12 months. The facility's policy mandates that each employee's job performance be reviewed and evaluated annually by the department director and reviewed by management. Interviews revealed that the Director of Nursing (DON) was responsible for conducting these evaluations but had not completed or signed off on any CNA performance evaluations, despite being present during the evaluations. The Human Resources representative confirmed the absence of signed evaluations for the two CNAs in question.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Pineville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Oaks Care Center | 1.8 mi | ★★★★★ | 7 | 0 |
| Legacy Nursing At St. Christina | 2.1 mi | ★★★★★ | 23 | 0 |
| Matthews Memorial Health Care Center | 3.1 mi | ★★★★★ | 10 | 0 |
| Tioga Community Care Center | 4.4 mi | ★★★★★ | 1 | 0 |
| The Summit | 5.3 mi | ★★★★★ | 10 | 0 |
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