Average — CMS composite of the measures below.
The next survey window likely opens around February 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 Health And Rehabilitation during CMS and state inspections, most recent first.
Surveyors observed a nurse leave four insulin pens unattended on top of a medication cart on two occasions while walking away and out of sight, with a resident seated next to the cart waiting for medication. Review of the same cart found several insulin and injectable pens in use without required open and expiration dates, as well as pens that remained on the cart past the discard timeframe specified by the manufacturer. The nurse acknowledged forgetting to date a newly opened insulin pen and not returning the pens to the correct cart, while leadership confirmed staff are expected to keep medications secured, label pens when opened, and remove expired medications.
Two residents experienced inaccurate medical record documentation when one NPO resident’s medications were ordered and recorded as given by mouth instead of via g-tube in the EMR and MAR, despite staff administering them through the g-tube, and another resident’s ordered compression hose were repeatedly charted on the TAR as applied and removed even though staff reported the resident did not wear them and frequently refused the treatment, with refusals not properly documented.
The facility failed to provide scheduled group outings for residents, despite their expressed importance for well-being. Residents had not participated in external activities for over a year due to transportation limitations, leading to feelings of sadness and depression. The facility's single van, primarily used for medical appointments, could not accommodate the demand for outings, and no alternative transportation solutions had been implemented.
A nurse failed to wear gloves while performing a blood glucose test on a resident, contrary to the facility's infection control policies. The facility's guidelines require gloves during procedures involving potential blood exposure, but the nurse used bare hands to handle equipment and dispose of supplies. Interviews with the DON and Administrator confirmed the expectation for adherence to these protocols.
Unsecured and Improperly Labeled Insulin and Injectable Medications on Medication Cart
Penalty
Summary
The deficiency involves failure to secure and properly manage insulin and other injectable medications on a medication cart. During continuous observation of medication administration with one nurse on Medication Cart #1, four insulin injector pens were left unattended on top of the cart while the nurse twice walked away and out of eyesight of the cart. On both occasions, a resident was seated beside the cart waiting for medication while the unsecured insulin pens remained on top. The nurse later stated the pens belonged on another cart, acknowledged she had placed them on Cart #1 earlier when administering insulin because the medication aide could not give insulin, and admitted she did not realize she had left them unsecured when she walked away. Further observation of Medication Cart #1 revealed multiple issues with labeling and expiration of injectable medications. One Novolog pen for a resident had 12 units remaining and a blank label with no open date or expiration date. One Lantus pen for another resident had 80 units remaining and a blank label with no open date or expiration date. A Novolog pen for a third resident had 100 units remaining and a blank label with no open date or expiration date; the nurse later stated she had opened it at noon the same day and forgot to date it. An Aspart pen for another resident was labeled as opened on 01/08/26 with an expiration date of 02/04/26, despite manufacturer directions stating Aspart pens should be discarded 28 days after opening. A Liraglutide injection pen for another resident was labeled as opened on 01/10/26 with an expiration date of 02/06/26, although manufacturer directions indicated it should be discarded 30 days after opening. The DON and Administrator confirmed that staff are expected to keep medications secured, label injector pens with open and expiration dates at the time of opening, and remove expired medications from use.
Inaccurate Medication Routes and Treatment Documentation in Medical Records
Penalty
Summary
The deficiency involves failures to maintain accurate and complete medical records for two residents. For one resident with a history of severe dysphagia from a previous stroke and an NPO (nothing by mouth) diet order, multiple medication orders in the electronic medical record (EMR) were entered with the route as "by mouth" instead of via gastrostomy tube (g-tube). These included lorazepam, sertraline, and geri-tussin DM. The March Medication Administration Record (MAR) showed these medications as administered as ordered by mouth over multiple days, even though the resident was NPO. Nursing staff who regularly cared for this resident reported that all medications were always crushed and administered through the g-tube and that the resident did not receive medications by mouth. One nurse stated she had not noticed that some medications were ordered by mouth on the MAR, while another nurse acknowledged she had noticed the incorrect route but did not correct it due to time constraints. The Nurse Practitioner confirmed that she entered the orders and that the EMR defaulted to the oral route, which she failed to manually change to g-tube, resulting in inaccurate documentation of the administration route in the medical record. For a second resident, there was an order for knee-high compression hose to be applied in the morning and removed in the evening. The March Treatment Administration Record (TAR) showed staff initials indicating that the compression hose were applied and removed daily, with one exception. However, observation revealed the resident was not wearing compression hose, and the nurse aide responsible for treatments stated the resident did not wear them and could not explain why the TAR had been initialed as if they were applied. A nurse, the ADON, and the DON all reported that this resident frequently refused compression hose and that refusals should have been documented as such on the TAR rather than initialing as if the treatment had been completed, indicating inaccurate documentation of treatment administration and refusals in the medical record.
Lack of Scheduled Group Outings for Residents
Penalty
Summary
The facility failed to provide group activities outside of the facility for residents who expressed the importance of such activities for their well-being. A review of the activity calendars for 2024 and January 2025 showed no scheduled activities outside the facility, despite the facility's proximity to various local amenities. Interviews with residents revealed that they had not participated in any group outings for over a year, which made them feel sad, lonely, and sometimes depressed. The residents expressed a desire to engage in activities such as dining at restaurants, shopping, and socializing outside the facility. The deficiency was further highlighted during a Resident Council meeting where multiple residents, including the Resident Council President, confirmed the lack of scheduled outings. They noted that the facility only had one van that could accommodate two wheelchair users, which was primarily used for medical appointments. The residents had discussed the issue with the Activities Director, who acknowledged the transportation limitations and the impact on residents' ability to participate in external activities. The Activities Director had attempted to address residents' needs by assisting with personal and online shopping, but recognized that these efforts did not replace the experience of leaving the facility. The Administrator, who had been with the facility since September 2023, confirmed the transportation challenges and the absence of scheduled outings since December 2023. He acknowledged the importance of external activities for residents' independence and socialization. The Administrator mentioned exploring options for additional transportation resources, but at the time of the report, no solution had been implemented to address the deficiency.
Failure to Follow Infection Control Protocols During Blood Glucose Testing
Penalty
Summary
The facility failed to implement its infection control policies and procedures when a nurse did not wear gloves while performing a capillary blood glucose test on a resident. The facility's policy on Personal Protective Equipment (PPE) requires staff to wear gloves during resident care activities where exposure to blood is likely. Additionally, the facility's Blood Glucose Monitoring policy specifies that gloves should be donned before performing the procedure and removed afterward. However, during an observation, Nurse #1 was seen performing a blood glucose test on a resident without wearing gloves. The nurse used bare hands to open an alcohol pad, wipe the resident's finger, and obtain a blood sample with a lancet, subsequently handling the glucometer and disposing of used supplies without gloves. Interviews with the Director of Nursing (DON) and the Administrator revealed that both expected nurses to adhere to the facility's guidelines for blood glucose monitoring, which include wearing gloves. The DON emphasized the importance of performing hand hygiene before and after glove use, while the Administrator reiterated the expectation for nurses to follow the facility's PPE and Blood Glucose Monitoring policies. Despite these expectations, the nurse's actions during the observed procedure did not align with the established protocols, leading to the identified deficiency.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oak Grove Healthcare | 3.7 mi | ★★★★★ | 1 | 0 |
| Willow Ridge Of Nc | 4.1 mi | ★★★★★ | 5 | 0 |
| Fair Haven Of Forest City, Llc | 7.7 mi | ★★★★★ | 3 | 0 |
| Fair Haven Home Inc | 8.3 mi | ★★★★★ | 2 | 0 |
| Deer Park Health And Rehabilitation | 16.8 mi | ★★★★★ | 3 | 3 |
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