Incident investigation·February 24, 2025

On February 24, 2025 at approximately 1:15 PM, Licensing Program Analysts (LPA), Farhaan Sarangi and Kayla Adkison arrived unannounced at Hilltop Springs Senior Living for the purpose of conducting a Case Managemen-Incident Inspection. LPAs met with the Assistant Executive Director, Olivia Brady and was granted access into the facility. LPAs toured the facility and observed the facility to be clean with all exits free from obstruction. LPAs observed sufficient perishable and non-perishable foods located in the kitchen. All three floors of the facility were observed to be in Title 22 compliance. On January 17, 2025, Community Care Licensing Division (CCLD) received an incident report indicating that a resident fell multiple times in the span of a couple of weeks. Memory Care Director reported that the Primary Care Physician was notified and the Care Plan was reviewed and updated accordingly. Resident is reportedly doing good at this time with no falls since January 2025. On January 22, 2025, Community Care Licensing Division (CCLD) received an incident report indicating that a resident had an unwitnessed fall and was found on the bathroom floor of the residents room. Administrator reported that the Primary Care Physician was notified and the Care Plan was reviewed and updated accordingly. Facility has since moved the resident to the Memory Care Unit and the resident is doing good at this time with no new falls since being in the Memory Care Unit On January 27, 2025, Community Care Licensing Division (CCLD) received an SOC 341 indicating that a resident was being verbally aggressive. The Caregiver on duty that day took the television privileges away from the resident. Administrator terminated the alleged Caregiver immediately and conducted staff training. LPA advised that if another incident of this same nature occurs again, a citation would be issued to the facility for Personal Rights. Administrator conducted staff training surrounding Personal Rights. (Report continued on LIC 809C) LPA advised that if another incident of this same nature occurs again, a citation would be issued to the facility for Personal Rights. Administrator conducted staff training surrounding Personal Rights. On January 28, 2025, Community Care Licensing Division (CCLD) received an incident report indicating that a resident had 14 falls. Facility staff reported that she is a two person transfer. Primary Care Physician has been notified and the Care Plan has been updated. LPAs observed the room to ensure it is safe for the resident in care. LPAs observed the room to be in Title 22 Compliance. On February 11, 2025, Community Care Licensing Division (CCLD) received an incident report indicating that a resident had an unwitnessed fall in which the resident sustained a leg fracture. Primary Care Physician was notified regarding the fall and fracture. Facility staff reported that the resident has since went to rehab and will transition back to the facility. Facility has not heard when the resident will be discharged back to the facility. No deficiencies were cited during today's Case Management-Incident Inspection. Exit interview was conducted, and a copy of this report was signed and given to Assistant Executive Director.