Inspection Reports for
Hilltop Manor Health & Rehabilitation Center
101 Kirkland Street, Union, MS, 39365
Back to Facility Profile43 Reports
Inspection Report — Aug 13, 2026
Annual Inspection
Date: Aug 13, 2026
Visit Reason
The State Agency conducted an annual re-certification survey at the facility from 8/11/26 through 8/13/26. During the survey, the SA determined that the facility was not in compliance with the Medicare and Medicaid regulations for participation and cited regulatory deficiencies F565, F689, F550, F584, F656, F658, F677, and F761.
Findings
The facility was found not in compliance with multiple deficiencies including failure to address resident grievances, unsafe smoking practices, lack of respect and dignity in care, unclean wheelchairs, incomplete care plans, failure to provide necessary ADL care, improper medication administration, and unsecured medication carts.
Deficiencies (8)
F0565 - Resident/Family Group and Response. The facility failed to act upon and resolve repeated Resident Council grievances related to food quality, staff attitudes, unanswered call lights, delayed assistance with care, housekeeping services, and availability of ice water for eight residents.
F0689 - Free of Accident Hazards/Supervision/Devices. The facility failed to provide a safe smoking environment by not ensuring protective smoking aprons were worn during smoking activities for two residents during three of four observed smoking activities.
F0550 - Resident Rights/Exercise of Rights. The facility failed to provide reasonable accommodation for residents' needs and preferences related to incontinence care and protection of beds, wheelchairs, and recliners for three residents, including removal of incontinent pads causing residents to use makeshift protections.
F0584 - Safe/Clean/Comfortable/Homelike Environment. The facility failed to ensure cleaning and disinfection of resident wheelchairs was completed for three residents, with wheelchairs observed to have thick brown or gray substances and food particles.
F0656 - Develop/Implement Comprehensive Care Plan. The facility failed to develop an ADL care plan for two residents, failed to implement care plan interventions for another resident's ADL needs, and failed to implement smoking apron requirements for two residents.
F0658 - Services Provided Meet Professional Standards. The facility failed to administer enteral flushes according to physician orders for one resident during medication administration observations.
F0677 - ADL Care Provided for Dependent Residents. The facility failed to provide timely toileting assistance, shower and nail care, and facial shaving for three residents reviewed for activities of daily living.
F0761 - Label/Store Drugs and Biologicals. The facility failed to ensure that medication carts were locked and secured while unattended for one medication cart observed on North Hall.
Report Facts
Deficiencies cited: 8
Inspection Report — Aug 12, 2026
Life Safety
Date: Aug 12, 2026
Visit Reason
The facility was surveyed for compliance with the 2012 Edition of the Life Safety Code (LSC) and Emergency Preparedness requirements on 08/12/2026.
Findings
The facility was found to be in compliance with all applicable Life Safety Code and Emergency Preparedness requirements. No deficiencies were cited during this survey.
Inspection Report — Mar 30, 2026
Complaint Investigation
Date: Mar 30, 2026
Visit Reason
The State Agency conducted three Complaint Investigations (CI MS#2797423, CI MS #2804922 and CI MS #2962788) at the facility on 3/30/26. The facility was found not in compliance related to complaint CI MS #2962788 for accident hazards and cited F0689. No deficient practice was found for the other two complaints.
Complaint Details
Three complaint investigations were conducted (CI MS#2797423, CI MS #2804922 and CI MS #2962788). Deficiency was cited only for CI MS #2962788 related to accident hazards. The other two complaints were found with no deficient practice.
Findings
F0689 - The facility failed to provide adequate supervision to prevent a cognitively impaired resident with a history of wandering from exiting the facility unattended. The resident was found outside unattended for approximately five minutes. The facility implemented corrective actions prior to survey entrance and was found in compliance as of 3/24/26.
Deficiencies (1)
F0689 - The facility failed to provide adequate supervision to prevent a cognitively impaired resident with a history of wandering from exiting the facility unattended for approximately five minutes.
Report Facts
Deficiencies cited: 1
Complaint investigations: 3
Inspection Report — Dec 16, 2025
Complaint Investigation
Date: Dec 16, 2025
Visit Reason
The State Agency conducted three Complaint Investigations (CI MS# 2652103, CI MS #2628534, and MS CI# 2631087) at the facility on 12/16/25. The SA investigated resident rights, environment, and accidents.
Complaint Details
Three complaint investigations (CI MS# 2652103, CI MS #2628534, and MS CI# 2631087) were conducted and the facility was found in compliance with no deficiencies cited.
Findings
The facility was found in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm.
Report Facts
Complaint investigations conducted: 3
Inspection Report — Aug 26, 2025
Complaint Investigation
Date: Aug 26, 2025
Visit Reason
On 08/26/25 the State Agency (SA) conducted an onsite complaint investigation, (CI) MS #504271, for alleged abuse of a Resident.
Complaint Details
CI MS #504271 for alleged abuse of a Resident. The SA determined the facility was in compliance and no deficiencies were cited.
Findings
The SA determined that the facility was in compliance with the Rules and Regulations for The Aged and Infirm state licensure requirements and no deficiencies were cited.
Report Facts
Complaint investigations: 1
Inspection Report — Jan 7, 2025
Date: Jan 7, 2025
Visit Reason
On 1/7/25 the State Agency (SA) conducted a desk review of the information that was provided to our agency related to the annual survey that was completed on 12/05/24. The information provided by the facility confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements of participation.
Findings
The State Agency is recommending that the facility be placed back in compliance effective 01/06/25. No deficiencies were cited in this desk review.
Inspection Report — Jan 7, 2025
Annual Inspection
Date: Jan 7, 2025
Visit Reason
On 01/07/25 the State Agency (SA) conducted a desk review of the information that was provided to our agency related to the annual survey that was completed on 12/05/24.
Findings
The information provided by the facility confirmed the facility was in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm. The SA is recommending that your facility be placed back in compliance effective 01/06/25.
Inspection Report — Dec 5, 2024
Routine
Date: Dec 5, 2024
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements for nursing home care, including resident environment, assessments, activities, medication management, infection control, and other care standards.
Findings
The facility was found deficient in multiple areas including failure to maintain clean bed linens for a resident, inaccurate Minimum Data Set (MDS) coding, incomplete PASRR screening, lack of weekend activities, improper PICC line care, unsecured medications, and failure to use enhanced barrier precautions during catheter care.
Deficiencies (7)
F 0584: The facility failed to provide clean bed linens for Resident #20, with observed dirty and stained sheets and pillowcases not changed as required.
F 0641: The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for Resident #5, resulting in incorrect assessment data.
F 0645: The facility failed to accurately submit PASRR information for Resident #54, omitting active mental illness diagnoses and psychotropic medication use.
F 0679: The facility failed to provide structured activities seven days a week, with no scheduled weekend activities for multiple residents.
F 0694: The facility failed to provide appropriate PICC line dressing care for Resident #10, with dressings not changed weekly as required.
F 0761: The facility failed to securely store medications for Residents #13 and #22, with medications found unsecured on bedside tables without proper orders or assessments.
F 0880: The facility failed to implement infection prevention by not using enhanced barrier precautions during catheter care for Resident #12.
Report Facts
Residents reviewed: 53
Residents sampled: 18
Residents reviewed for PASRR: 4
Residents observed for IV access: 4
Residents affected by lack of weekend activities: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) #1 | Confirmed dirty linens for Resident #20 and medication storage issues | |
| Director of Nursing (DON) | Confirmed multiple deficiencies including linen changes, MDS coding expectations, PICC line care, medication storage, and infection control | |
| MDS Nurse | Verified incorrect MDS coding for Resident #5 | |
| Social Service staff #1 | Confirmed inaccurate PASRR submission for Resident #54 | |
| Activity Director (AD) | Confirmed no scheduled weekend activities and described activity program | |
| Administrator | Acknowledged lack of weekend activities and impact on residents | |
| Restorative Certified Nursing Assistant (RCNA) | Described weekend activity responsibilities and limitations | |
| Registered Nurse (RN) #2 | Verified PICC line dressing issues for Resident #10 | |
| Registered Nurse (RN) #3 | Verified medication storage and self-administration issues for Resident #13 | |
| Treatment Nurse | Confirmed unauthorized medication in Resident #22's room | |
| Certified Nurse Assistant (CNA) #1 | Failed to use enhanced barrier precautions during catheter care | |
| Restorative CNA | Failed to use enhanced barrier precautions during catheter care | |
| Infection Control Nurse | Confirmed failure to implement enhanced barrier precautions |
Inspection Report — Dec 5, 2024
Annual Inspection
Date: Dec 5, 2024
Visit Reason
The State Agency (SA) conducted an annual survey at the facility from 12/2/24 through 12/5/24. During the survey, the SA determined that the facility was not compliance with the requirements for participation in Medicare and Medicaid and cited F584, F641, F645, F679, F694, F761, and F880.
Findings
The facility was found not in compliance with Medicare and Medicaid participation requirements, with deficiencies cited in areas including environment cleanliness, assessment accuracy, PASARR screening, activities programming, IV fluid care, medication storage, and infection control.
Deficiencies (7)
F0584 - Safe/clean/comfortable/homelike environment. The facility failed to provide a resident with clean bed linens, as evidenced by dirty, stained linens for Resident #20 that had not been changed timely, posing a sanitization concern.
F0641 - Accuracy of assessments. The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for Resident #5, incorrectly coding the Level II PASRR status, potentially affecting care.
F0645 - PASARR screening for mental disorder and intellectual disability. The facility failed to accurately submit Resident #54's information for Level II PASRR evaluation, omitting active mental health diagnoses and psychotropic medication use.
F0679 - Activities meet interest/needs each resident. The facility failed to provide structured activities seven days a week, lacking weekend activities for residents, negatively impacting their well-being and socialization.
F0694 - Parenteral/IV fluids. The facility failed to provide proper PICC line dressing care for Resident #10, with dressings not changed as ordered, increasing risk of infection.
F0761 - Label/store drugs and biologicals. The facility failed to securely store medications, with medications found unsecured in Resident #13 and #22's rooms without proper orders or assessments.
F0880 - Infection prevention and control. The facility failed to use enhanced barrier precautions during catheter care for Resident #12, increasing risk of infection transmission.
Report Facts
Deficiencies cited: 7
Inspection Report — Dec 3, 2024
Life Safety
Date: Dec 3, 2024
Visit Reason
The facility was surveyed for compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).
Findings
The facility was found to be in compliance with the Life Safety Code. There were no LSC deficiencies cited during this survey.
Inspection Report — Oct 29, 2024
Complaint Investigation
Date: Oct 29, 2024
Visit Reason
On October 28, 2024 the State Agency conducted four onsite complaint investigations: CI MS #25816 and CI MS #25819 alleging neglect and refusal to allow a Resident to speak to family via telephone; and CI MS #26045 and CI MS #26053 alleging a Resident lost 10% body weight in two weeks due to neglect.
Complaint Details
Four complaint investigations were conducted: CI MS #25816 and CI MS #25819 alleged neglect and refusal to allow telephone contact; CI MS #26045 and CI MS #26053 alleged significant weight loss due to neglect. The facility was found in compliance and no deficiencies were cited.
Findings
The State Agency determined the facility was in compliance with Medicare and Medicaid standards and no deficiencies were cited.
Report Facts
Complaint investigations conducted: 4
Inspection Report — Jun 20, 2024
Complaint Investigation
Date: Jun 20, 2024
Visit Reason
The State Agency conducted two onsite complaint investigations, CI MS #25083 alleging the facility would not allow the grandson to talk to the resident on the telephone and placed the grandson on hold for long periods of time; and CI MS #25419 alleging a resident was illegally discharged without the knowledge of the resident or his family.
Complaint Details
CI MS #25083 alleged the facility would not allow the grandson to talk to the resident on the telephone and placed the grandson on hold for long periods of time; CI MS #25419 alleged a resident was illegally discharged without the knowledge of the resident or his family. The complaints were investigated and no deficiencies were cited.
Findings
The State Agency determined that the facility was in compliance with the Standards for Participation in Medicare and Medicaid and no deficiencies were cited.
Report Facts
Complaints investigated: 2
Inspection Report — Apr 15, 2024
Complaint Investigation
Date: Apr 15, 2024
Visit Reason
On 04/15/24 the State Agency (SA) conducted two (2) complaint investigations (CI MS #24753 and CI MS #24765). CI MS #24753 was an anonymous complaint that alleged abuse and neglect of a resident and CI MS #24765 alleged neglect related to bowel and bladder.
Complaint Details
Two complaint investigations were conducted: CI MS #24753 alleging abuse and neglect, and CI MS #24765 alleging neglect related to bowel and bladder. Both complaints were determined to be unsubstantiated with no deficiencies cited.
Findings
The SA determined that the facility was in compliance with the rules and regulations for the Aged and Infirmed and no deficiencies were cited.
Report Facts
Complaint investigations conducted: 2
Inspection Report — Mar 26, 2024
Complaint Investigation
Date: Mar 26, 2024
Visit Reason
On 03/26/24 the State Agency (SA) conducted an on site complaint investigations (CI) for CI MS #24154 for alleged neglect of a resident; and CI MS #24452 for laundry concerns; and CI MS #24540 for misappropriation of property.
Complaint Details
Complaint investigations CI MS #24154 for alleged neglect of a resident; CI MS #24452 for laundry concerns; and CI MS #24540 for misappropriation of property were conducted and no deficiencies were cited.
Findings
The SA determined that the facility was in compliance with the requirements of participation in Medicare and Medicaid services and no deficiencies were cited.
Report Facts
Complaints investigated: 3
Inspection Report — Sep 25, 2023
Life Safety
Date: Sep 25, 2023
Visit Reason
On 09/25/23 the State Agency (SA) conducted a desk review of the information that was provided to our agency related to the annual survey that was conducted on 08/02/23.
Findings
The information provided by the facility confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with applicable provisions of the 2012 (existing) Edition of the Life Safety Code (LSC). The SA is recommending that your facility be placed back in compliance effective 09/25/23.
Inspection Report — Sep 19, 2023
Annual Inspection
Date: Sep 19, 2023
Visit Reason
On 09/19/23 the State Agency (SA) conducted a desk review of the information that was provided related to the annual survey completed on 08/03/23. The information confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements of participation.
Findings
The State Agency is recommending that the facility be placed back in compliance effective 09/14/23. No deficiencies were cited in this desk review.
Inspection Report — Aug 3, 2023
Annual Inspection
Date: Aug 3, 2023
Visit Reason
An annual recertification survey and complaint investigations (CI) MS #21902, CI MS #22052, and CI MS #22205 were conducted from 7/31/23 through 8/3/23 at the facility. During the survey, the facility was found not to be in compliance with the requirements for participation in Medicare and Medicaid.
Complaint Details
Complaint investigations CI MS #21902, CI MS #22052, and CI MS #22205 were conducted. The facility was found not in compliance for CI MS #21902 related to staffing and call bells not being answered, not in compliance with CI MS #22205 related to grooming, odors, staffing and call bells, and not in compliance with CI MS #22052 regarding call bells not being answered. The facility was in compliance with complaints related to residents left soiled, falls, insufficient food, and residents not being repositioned or left wet.
Findings
The facility was found not in compliance with multiple requirements including resident self-determination, safe and clean environment, grievance resolution, comprehensive care planning, ADL care, mobility maintenance, respiratory care, sufficient staffing, infection control, and pest control.
Deficiencies (10)
F0561 - The facility failed to honor the choice of a resident (#36) to get up early as evidenced by observations, interviews, and record reviews.
F0584 - The facility failed to maintain a clean environment free of odors and provide sufficient clean linens as evidenced by urine odors, dirty walls and side rails, and insufficient towels and washcloths.
F0585 - The facility failed to resolve grievances timely for one resident (#49) regarding bathing and for five residents (#9, #14, #28, #41, #53) regarding foul odors inside the facility.
F0641 - The facility failed to accurately code a Minimum Data Set (MDS) related to weight loss for one resident (#11).
F0656 - The facility failed to develop and implement person-centered care plans for residents receiving oxygen (#23, #106), respecting resident choice (#36), and for dependent residents (#22, #35, #44, #29).
F0677 - The facility failed to provide adequate ADL care including shaving, nail care, and bathing for five dependent residents (#22, #35, #38, #44, #49).
F0688 - The facility failed to apply a physician-ordered splint to a resident (#29) to prevent contractures.
F0695 - The facility failed to post oxygen in use signage on the door and failed to store oxygen tubing in a bag to prevent contamination for two residents (#23, #106).
F0925 - The facility failed to maintain an effective pest control program to prevent flying insects in the dining room, kitchen, and resident rooms.
F0725 - The facility failed to provide sufficient nursing staff to meet resident care needs on two of four survey days, resulting in delayed care and unanswered call lights.
Report Facts
Deficiencies cited: 11
Inspection Report — Aug 3, 2023
Routine
Date: Aug 3, 2023
Visit Reason
The inspection was a routine regulatory survey to assess compliance with healthcare facility regulations, including resident care, environment, staffing, and infection control.
Findings
The facility was found deficient in honoring resident choice for care timing, maintaining a clean and odor-free environment, resolving grievances timely, accurate resident assessments, developing and implementing person-centered care plans, providing adequate assistance with activities of daily living, applying ordered splints, posting oxygen use signage, storing oxygen tubing properly, maintaining sufficient nursing staff, and controlling pest infestations.
Deficiencies (11)
F 0561: The facility failed to honor the choice of Resident #36 to get up early and have a bath on the 11 PM-7 AM shift due to staffing shortages.
F 0584: The facility failed to maintain a clean environment free of odors and provide sufficient clean linen for two of four survey days, evidenced by urine odors, dirty walls, and lack of towels and washcloths.
F 0585: The facility failed to resolve grievances timely for bathing and foul odors for multiple residents, with complaints about urine and feces smells persisting.
F 0641: The facility failed to accurately code a Minimum Data Set (MDS) for Resident #11 related to weight loss, incorrectly marking it as physician prescribed.
F 0656: The facility failed to develop and implement person-centered care plans for seven residents, including oxygen care, resident preferences, ADL assistance, and splint use.
F 0677: The facility failed to provide adequate care and assistance with activities of daily living, including bathing, shaving, nail care, and adherence to splint orders for multiple residents.
F 0688: The facility failed to apply a physician-ordered left-hand splint for Resident #29, risking worsening contractures.
F 0695: The facility failed to post oxygen in use signage on doors for Residents #23 and #106 receiving respiratory care.
F 0725: The facility failed to provide sufficient nursing staff on two of four survey days, resulting in unmet resident care needs and delayed responses to call lights.
F 0880: The facility failed to store oxygen tubing in a bag to prevent contamination and infection for Residents #23 and #106.
F 0925: The facility failed to maintain an effective pest control program to prevent flying insects, with multiple observations of flies in dining, kitchen, and resident areas.
Report Facts
Residents reviewed: 23
Residents reviewed: 59
Residents affected: 4
Staff on duty: 3
Call ins: 5
Call ins: 5
Call ins: 2
Facility staffing need: 8
Facility staffing need: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Confirmed bath schedule and staffing issues related to Resident #36 |
| Certified Nurse Assistant #1 | CNA | Reported staffing shortages and bath delays for Resident #36 |
| Director of Nurses | DON | Confirmed staffing shortages, care plan deficiencies, and oxygen signage issues |
| Assistant Director of Nurses | ADON | Confirmed staffing shortages and odor issues |
| Social Worker | SW | Handled grievances and follow-up for Resident #49 |
| Administrator | Administrator | Provided statements on staffing, grievances, and pest control |
| Licensed Practical Nurse #2 | LPN | Reported Resident #49 bath refusals and oxygen cannula observations |
| Registered Nurse #1 | RN | Confirmed care plan noncompliance for splint application |
| Wound Nurse | Wound Nurse | Did not apply splint as ordered for Resident #29 |
| Occupational Therapist | OT | Confirmed splint order for Resident #29 |
| Certified Nurse Assistant #5 | CNA | Reported Resident #35 did not get a bath |
| Certified Nurse Assistant #6 | CNA | Reported Resident #38's nails were long and dirty |
| Dietary Manager | DM | Confirmed fly infestation in kitchen |
Inspection Report — Aug 2, 2023
Life Safety
Date: Aug 2, 2023
Visit Reason
The facility underwent a Life Safety Code survey to assess compliance with the 2012 Edition of the Life Safety Code of the National Fire Protection Association (NFPA).
Findings
The facility was found to have a deficiency related to exit discharge maintenance, specifically a cracked and uneven sidewalk at the South Hall exit that affected safe egress.
Deficiencies (1)
K0271 - The facility failed to properly maintain exit egress as evidenced by a cracked and unlevel sidewalk from the South Hall exit, which was not a smooth, continuous surface.
Report Facts
Deficiencies cited: 1
Inspection Report — Dec 28, 2022
Complaint Investigation
Date: Dec 28, 2022
Visit Reason
The State Agency conducted a complaint survey, MS00019726 and MS00020166, at the facility from 12/27/22 through 12/28/2022.
Complaint Details
Complaint survey MS00019726 and MS00020166 related to Family/Visitor Abuse or Misappropriation was not substantiated and no deficiencies were cited.
Findings
The facility was found in compliance with the Mississippi Regulations for Minimum Standards for Institutions for Aged or Infirm. No deficiencies were cited and the complaints related to Family/Visitor Abuse or Misappropriation were not substantiated.
Report Facts
Complaints investigated: 2
Inspection Report — Oct 20, 2022
Complaint Investigation
Date: Oct 20, 2022
Visit Reason
On 10/20/22 the State Agency (SA) conducted an on site complaint investigation for MS00019604 and MS00019605 which alleged that the facility neglected to deliver care to a resident after a fall.
Complaint Details
Complaint numbers MS00019604 and MS00019605 alleged neglect to deliver care to a resident after a fall; the allegations were not substantiated and no deficiencies were cited.
Findings
The SA did not substantiate the allegation and no deficiencies were cited. The SA determined that the facility was in substantial compliance with the regulations for The Aged and Infirmed.
Report Facts
Complaints investigated: 2
Inspection Report — Apr 20, 2022
Follow-Up
Date: Apr 20, 2022
Visit Reason
The State Agency conducted a Post-Certification Revisit on 04/18/22 through 04/20/22 for the Annual Recertification Survey completed on 1/6/22 and the Federal Comparative Health and COVID-19 Survey completed on 2/25/22 at the facility.
Findings
The State Agency determined that the facility was in compliance with the requirements for participation in Medicare and Medicaid. The facility was placed back into compliance for multiple previously cited deficiencies effective 03/06/2022.
Report Facts
Deficiencies cited: 12
Inspection Report — Feb 25, 2022
Routine
Date: Feb 25, 2022
Visit Reason
A Federal Monitoring Comparative Survey and COVID-19 survey conducted by Healthcare Management Solutions, LLC on behalf of CMS on February 22-25, 2022, identified noncompliance with the Federal Participation requirements. The desk revisit survey conducted by the Mississippi State Survey Agency (SSA) is rescinded.
Findings
The facility was found noncompliant with multiple federal participation requirements including safe environment, ADL care, respiratory care, food safety, infection prevention and control, and resident call system.
Deficiencies (6)
F0584 - Safe/clean/comfortable/homelike environment. The facility failed to provide a safe, clean, comfortable, and homelike environment including adequate lighting, temperature control, and maintenance of resident rooms.
F0677 - ADL care provided for dependent residents. The facility failed to provide necessary services to maintain good nutrition, grooming, and personal and oral hygiene for residents unable to carry out activities of daily living.
F0695 - Respiratory/tracheostomy care and suctioning. The facility failed to ensure residents needing respiratory care, including tracheostomy care and suctioning, received care consistent with professional standards and their care plans.
F0812 - Food procurement, store/prepare/serve-sanitary. The facility failed to procure, store, prepare, distribute, and serve food in accordance with professional food service safety standards.
F0880 - Infection prevention and control. The facility failed to establish and maintain an infection prevention and control program that includes surveillance, reporting, isolation procedures, hand hygiene, and annual review.
F0919 - Resident call system. The facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system that relays the call directly to staff or a centralized work area.
Report Facts
Deficiencies cited: 6
Inspection Report — Feb 25, 2022
Annual Inspection
Date: Feb 25, 2022
Visit Reason
On 2/25/22 the State Agency (SA) conducted a desk review of the information that was provided related to the annual survey conducted on 01/06/22. The information confirmed the facility had put measures in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements of participation.
Findings
The State Agency is recommending that the facility be placed back in compliance effective 02/21/22. No deficiencies were cited in this desk review.
Inspection Report — Jan 6, 2022
Routine
Date: Jan 6, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident care, facility cleanliness, infection control, respiratory care, food safety, and call system functionality at Hilltop Manor Health and Rehabilitation Center.
Findings
The facility was found to have multiple deficiencies including failure to maintain a clean and odor-free environment, inadequate activities of daily living care for residents, improper labeling and storage of oxygen therapy equipment, unsanitary kitchen conditions, failure to implement infection prevention protocols including hand hygiene and equipment disinfection, and a non-functioning call light system for one resident.
Deficiencies (6)
F 0584: The facility failed to maintain a clean and odor-free environment for two of three days of survey, with observations of urine odors, dirty floors, spills, and unclean shower rooms.
F 0677: The facility failed to provide adequate activities of daily living care, evidenced by long facial and neck hair and long fingernails for two of 24 residents reviewed.
F 0695: The facility failed to properly label, date, and store oxygen nebulizer masks and tubing for two of 12 residents receiving oxygen therapy, increasing infection risk.
F 0812: The facility failed to provide a safe and clean environment for food preparation and storage, with observations of unlabeled food, dirty pans, and an ice machine with black buildup and contamination.
F 0880: The facility failed to prevent possible infection spread by staff not performing hand hygiene during meal tray distribution and not disinfecting multiple use vital sign equipment between residents on two hallways.
F 0919: The facility failed to ensure a working call system for one resident, with the call light not functioning and no alternate call device provided, resulting in delayed assistance.
Report Facts
Residents reviewed for ADL care: 24
Residents receiving oxygen therapy: 12
Kitchen tours conducted: 3
Residents affected by infection control issues: 2
Resident call lights in facility: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #3 | Certified Nursing Assistant | Named in infection control hand hygiene and ADL care findings. |
| CNA #4 | Certified Nursing Assistant | Named in infection control hand hygiene and ADL care findings. |
| CNA #5 | Certified Nursing Assistant | Named in infection control equipment disinfection finding. |
| RN #1 | Registered Nurse | Confirmed oxygen therapy equipment storage issues. |
| DON | Director of Nursing | Interviewed regarding ADL care, infection control, and call light issues. |
| District Housekeeping Manager | Interviewed regarding cleaning routines and floor care. | |
| Housekeeping Supervisor | Interviewed regarding cleaning routines and floor care. | |
| Dietary Manager | Interviewed regarding kitchen cleanliness and cleaning schedules. | |
| Director of Nurses (DON) | Director of Nursing | Confirmed infection control and call light issues. |
| Maintenance Director | Interviewed regarding call light repair and ice machine cleaning. | |
| CNA #1 | Certified Nursing Assistant | Named in infection control hand hygiene findings. |
| CNA #2 | Certified Nursing Assistant | Failed to report call light issue for Resident #8. |
Inspection Report — Jan 6, 2022
Annual Inspection
Date: Jan 6, 2022
Visit Reason
The State Agency (SA) conducted a recertification survey at the facility from 01/4/22 through 01/6/22. The SA determined the facility was not in compliance with the requirements for participation in Medicare and Medicaid related to failure to perform hand hygiene, cleaning multiple use equipment, maintaining a clean environment, improper storage of respiratory equipment, not labeling oxygen equipment, an unsanitary dietary department, a nonfunctioning call light, and failure to provide appropriate Activities of Daily Living (ADL) care for residents.
Findings
The facility was found not in compliance with multiple deficiencies including failure to maintain a clean environment, failure to provide ADL care for dependent residents, improper respiratory equipment storage and labeling, unsanitary food preparation and storage, failure to prevent infection spread, and a nonfunctioning resident call system.
Deficiencies (6)
F0584 - Safe/clean/homelike environment. The facility failed to maintain a clean and odor-free environment for two of three days of survey, including urine odors in hallways, dirty floors, and unclean shower rooms with mold and buildup.
F0677 - ADL care provided for dependent residents. The facility failed to provide necessary grooming and nail care for two of 24 dependent residents, evidenced by long facial and neck hair and long fingernails.
F0695 - Respiratory/tracheostomy care and suctioning. The facility failed to properly label, date, and store oxygen nebulizer masks and tubing for two residents receiving oxygen therapy, risking contamination.
F0812 - Food procurement, store/prepare/serve-sanitary. The facility failed to maintain a safe and clean environment for food preparation and storage, including undated food and milk, cookware with carbon buildup, and a contaminated ice machine.
F0880 - Infection prevention & control. The facility failed to prevent possible spread of infection by not performing hand hygiene during meal tray distribution and not cleaning multiple use blood pressure cuff and oxygen saturation monitor between residents.
F0919 - Resident call system. The facility failed to ensure the call system was working for one resident, who had no alternate device to call for assistance when the call light was not functioning.
Report Facts
Deficiencies cited: 6
Inspection Report — Jan 5, 2022
Routine
Date: Jan 5, 2022
Visit Reason
This facility was surveyed under the Centers for Medicare Medicaid Services (CMS) COVID-19 Emergency Declaration Blanket 1135 Waivers for Health Care Provider.
Findings
There were no Life Safety Code deficiencies cited during this survey. The facility meets the applicable provisions of the 2012 Edition of the Life Safety Code.
Inspection Report — Jan 5, 2022
Life Safety
Date: Jan 5, 2022
Visit Reason
Survey conducted on 01/05/22 reveals the above facility meets all applicable Federal, State and local emergency preparedness requirements.
Findings
The facility was found in compliance with all applicable Federal, State and local emergency preparedness requirements.
Inspection Report — Nov 24, 2021
Routine
Date: Nov 24, 2021
Visit Reason
On 11/24/21 the State Agency (SA) conducted a desk review of the information that was provided related to the Focused Infection Control and Emergency Preparedness survey conducted on 10/6/21.
Findings
The information provided by the facility confirmed that measures were put in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements. The State Agency is recommending the facility be placed back in compliance effective 11/5/21.
Inspection Report — Nov 23, 2021
Complaint Investigation
Date: Nov 23, 2021
Visit Reason
The State Agency (SA) conducted a complaint survey, MS00018260 at the facility on 11/23/2021.
Complaint Details
Complaint MS00018260 alleged offensive odors in the facility; the complaint was not substantiated and no deficiencies were cited.
Findings
The facility was found in compliance with Medicare and Medicaid requirements. No deficiencies were cited and the complaint for offensive odors was not substantiated.
Report Facts
Complaint count: 1
Inspection Report — Oct 6, 2021
Routine
Date: Oct 6, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 10/06/21. The facility was found to not be in compliance with 42 CFR §483.80 infection control regulations with CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19 and was cited F880.
Findings
The facility failed to prevent the possible spread of infection on one of three hallways observed, specifically the north hallway, due to improper use of a floor fan blowing air from a COVID positive resident's room with the door open. Staff interviews and observations confirmed that the fan was placed near the open door of a COVID positive resident, potentially spreading the virus.
Deficiencies (1)
F0880 - Infection Prevention & Control. The facility failed to prevent the possible spread of infection on one of three hallways observed due to a floor fan blowing air from a COVID positive resident's room with the door open, contrary to infection control policies.
Report Facts
Deficiencies cited: 1
Inspection Report — Oct 6, 2021
Life Safety
Date: Oct 6, 2021
Visit Reason
The State Agency (SA) conducted an emergency preparedness visit to evaluate the emergency status at the facility on 10/06/21.
Findings
The SA found the facility to be in compliance with participation for Medicare and Medicaid Services and no deficiencies were cited.
Inspection Report — Jul 8, 2021
Complaint Investigation
Date: Jul 8, 2021
Visit Reason
The State Agency conducted a complaint survey investigating MS CI #17061, MS CI #17380, and MS CI #17702 from 7/7/2021 through 7/8/2021.
Complaint Details
Complaint investigation of MS CI #17061, MS CI #17380, and MS CI #17702; the facility was found in compliance with no deficiencies cited.
Findings
The facility was found in compliance with the requirements of participation in Medicare and Medicaid during the complaint survey.
Report Facts
Complaint count: 3
Inspection Report — Jul 7, 2020
Routine
Date: Jul 7, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 7/7/20.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report — Jul 7, 2020
Routine
Date: Jul 7, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 7/7/2020.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).
Inspection Report — May 24, 2020
Routine
Date: May 24, 2020
Visit Reason
A Covid-19 Focused Infection Control Survey was conducted by the State Agency (SA) on 5/24/20.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19.
Inspection Report — Oct 17, 2019
Complaint Investigation
Date: Oct 17, 2019
Visit Reason
The State Agency conducted a complaint survey MS #16269 on 10/17/19. During the survey, the SA substantiated MS #16269 for misappropriation and determined the facility was out of compliance with Medicare and Medicaid participation requirements.
Complaint Details
Complaint Investigation MS #16269 substantiated for misappropriation related to staff stealing a resident's bank card.
Findings
F0602 - The facility failed to keep residents free from misappropriation when a staff member stole Resident #1's bank card and used it for personal charges totaling $2,285.59. The staff member was terminated and the facility conducted staff reeducation and implemented measures to secure residents' valuables.
Deficiencies (1)
F0602 - The facility failed to keep residents free from misappropriation when a staff member stole Resident #1's bank card and used it for personal charges totaling $2,285.59.
Report Facts
Deficiencies cited: 1
Inspection Report — Aug 27, 2019
Complaint Investigation
Date: Aug 27, 2019
Visit Reason
The State Agency conducted a complaint survey MS# 16008 from 8/26/19 to 8/27/19, and determined one (1) of nine (9) areas of concern was substantiated; strong urine odors. The SA was unable to substantiate other complaints of rats/roaches, no linen, dirty pads, dirty environment, washing machine broken, low staffing, pressure ulcer concerns, and staff keeping residents heavily sedated.
Complaint Details
Complaint survey MS# 16008 substantiated one of nine areas of concern: strong urine odors. Other complaints were not substantiated.
Findings
The facility was found not in compliance due to strong urine odors throughout the facility, particularly between rooms 115 and 129. The facility failed to maintain a sanitary and comfortable environment as evidenced by untied soiled linen and trash bags causing odors.
Deficiencies (1)
F0921 - The facility failed to provide a sanitary and comfortable environment as evidenced by strong urine odors throughout the facility on two of three observations in the hallway, with untied soiled linen and trash bags contributing to the odors.
Report Facts
Deficiencies cited: 1
Areas of concern: 9
Inspection Report — Mar 21, 2019
Annual Inspection
Date: Mar 21, 2019
Visit Reason
A standard survey was conducted at Hilltop Manor Health and Rehabilitation from March 18, 2019 through March 21, 2019.
Findings
The standard survey revealed that the facility was in substantial compliance with Medicare/Medicaid regulations at 42 Code of Federal Regulations (C.F.R.) Part 483, Subpart B-Requirements for Long Term Care Facilities.
Inspection Report — Mar 21, 2019
Annual Inspection
Date: Mar 21, 2019
Visit Reason
The State Agency (SA) conducted an annual recertification survey on March 19, 2019.
Findings
The facility was found in compliance for State Licensure requirements. No deficiencies were cited.
Inspection Report — Aug 7, 2018
Complaint Investigation
Date: Aug 7, 2018
Visit Reason
A complaint investigation was conducted on August 7, 2018 in the facility.
Complaint Details
CI MS#15340: A complaint investigation was conducted and was unsubstantiated with no deficiencies cited.
Findings
The investigation was unsubstantiated with no deficiencies cited.
Inspection Report — Nov 29, 2017
Complaint Investigation
Date: Nov 29, 2017
Visit Reason
A complaint investigation was conducted on November 29, 2017 in the facility.
Complaint Details
CI MS#14879: A complaint investigation was conducted and substantiated with no deficiencies cited.
Findings
The complaint investigation was substantiated with no deficiencies cited.
Report Facts
Complaints investigated: 1
Inspection Report — Jun 1, 2017
Annual Inspection
Date: Jun 1, 2017
Visit Reason
The State Survey Agency (SA) conducted an annual recertification survey at the facility from 05/30/17 to 06/01/17. During the survey, the SA determined the facility was not in compliance with Medicare and Medicaid requirements for participation.
Findings
The facility was found not in compliance with Medicare and Medicaid requirements due to medication errors and infection control deficiencies. Two medication errors were observed, and failures in infection control practices were noted including improper glove use and hand hygiene.
Deficiencies (2)
F0332 - Free of medication error rates of 5% or more. The facility failed to maintain a medication error rate of less than 5%, evidenced by two medication errors in 25 medication administrations observed, including medications given at the wrong time to Resident #14.
F0441 - Infection control, prevent spread, linens. The facility failed to perform incontinent care to prevent cross contamination for Resident #4 and failed to wash hands between residents during glucose finger-sticks for Resident #1 and Unsampled Resident A.
Report Facts
Deficiencies cited: 2
4 CMS Surveys
CMS Survey — Aug 3, 2023
Aug 3, 2023
CMS Survey — Jan 6, 2022
Jan 6, 2022
CMS Survey — Aug 3, 2023
Aug 3, 2023
CMS Survey — Dec 5, 2024
Dec 5, 2024
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