Inspection visit
Health inspection
21 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 21 deficiencies, 1 of them serious (actual harm or immediate jeopardy). The full statement and the facility’s plan of correction follow, verbatim from the federal record.
145862
11/01/2023
Hilltop Skilled Nsg & Rehab
910 West Polk Street Charleston, IL 61920
F 0558
Reasonably accommodate the needs and preferences of each resident.
Level of Harm - Minimal harm or potential for actual harm
Based on observation, interview, and record review the facility failed to ensure a call light was in reach for one resident (R213) of 16 residents reviewed for call lights in a sample list of 34.
Residents Affected - Few
Findings Include: R213's Order Summary Report printed 11/1/23 at 3:10PM documents R213 was admitted to the facility 10/21/23 with diagnoses of Extensive Heart and Lung Disease and chronic Kidney Disease for Hospice care. On 10/30/23 at 3:20 PM R213 was resting in her bed. R213 stated I can't get to my call light. I'm thirsty, I want some ice, and I need straightened out in bed and I can't reach my call light. R213's call light was observed on the floor between the left side of the bed and the wall. No staff were observed in the room or the hall outside R213's room. On 10/31/23 at 3:15 PM R213 was resting in her bed. R213's call light was observed lying on the floor between the left side of the bed and the wall. V27, Certified Nurse's Aide (CNA) entered the room. V27 stated The call light fell off. All residents should have a call light in reach at all times. On 10/31/23 at 11:00AM V2, Director of Nursing stated that while the facility doesn't have a specific written policy for call lights, All residents should always have a call light within reach.
Page 1 of 28
145862
145862
11/01/2023
Hilltop Skilled Nsg & Rehab
910 West Polk Street Charleston, IL 61920
F 0580
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to notify the resident's representative of a change in condition for one resident (R20) of 16 residents reviewed for condition change in a sample list of 34 residents.
Findings include: R20's Care Plan revised 10/11/23 includes the following diagnoses: Type II diabetes Mellitus, Heart Disease, Anxiety, Dementia, Psychotic Disturbance, Mood Disorder, and Chronic Kidney Disease. R20's Minimum Data Set, dated [DATE] documents R20 is severely cognitively impaired. R20's Face Sheet reviewed 10/30/23 documents V28 is R20's resident representative and Power of Attorney. On 10/30/23 at 12:37 PM V28 stated (R20) had diarrhea and black stool in July and the facility did not notify me. It turned out to be C-Diff (Clotridoides difficile) and they didn't let me know that either. R20's Progress note dated 7/4/23 at 11:15PM documents (R20) has large black foul smell stool. (R20) lethargic with temperature of 100.4, blood pressure 106/50,16 respirations, and 110 pulse. (R20) refuses to go to the hospital at this time for further evaluation. There is no documentation to support V28 was notified of this change in condition. R20's Progress note dated 7/5/23 at 12:00AM documents (R20) has another large black foul loose stool. Temperature 100.5, blood pressure 107/48, pulse 109, respirations 15. (R20) lethargic. Sending (R20) out to (Local hospital) for further evaluation. There is no documentation to support V28 was notified of this change in condition. R20's Progress note dated 7/5/23 at 3:12AM documents, Nurse from (local hospital) called with update. Going to admit (R20) with elevated troponin level and Potassium of 2.7, called (V28) POA (Power of Attorney) No answer at this time. There is no documentation to support any message was left or additional attempts were made to notify V28. R20's Progress note dated 7/10/23 at 3:51PM documents Report from (local hospital) given to this writer. Nurse (from hospital) stated (R20) tested positive for C Diff and a Urinary Tract Infection. (R20) placed on oral vancomycin. (R20) had urinary retention and was straight cathed (catheterized) there twice. There is no documentation to support the facility attempted to notify V28 of this information. The facility policy Acute Change in Condition revised 1/23/23 does not address the requirement to notify resident representative of condition change. On 11/1/23 at 1:00PM V1, Administrator stated It is my expectation we will always notify family or resident representative of any change in our resident's condition.
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Page 2 of 28
145862
11/01/2023
Hilltop Skilled Nsg & Rehab
910 West Polk Street Charleston, IL 61920
F 0623
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Based on interview and record review the facility failed to notify the resident's representative of a transfer to the hospital for one resident (R20) of 16 residents reviewed for condition change in a sample list of 34 residents.
Findings include: R20's Care Plan revised 10/11/23 includes the following diagnoses: Type II diabetes Mellitus, Heart Disease, Anxiety, Dementia, Psychotic Disturbance, Mood Disorder, and Chronic Kidney Disease. R20's MDS (Minimum Data Set) dated 9/27/23 documents R20 is severely cognitively impaired. R20's Face Sheet reviewed 10/30/23 documents V28 is R20's resident representative and Power of Attorney. On 10/30/23 at 12:37 PM V28 stated (R20) had diarrhea and black stool in July and the facility did not notify me. It turned out to be C-Diff (Clostridium difficile) and they didn't let me know that either. I didn't even know they sent (R20) to the Emergency Room. R20's Progress note dated 7/5/23 at 12:00AM documents (R20) has another large black foul loose stool. Temperature 100.5, blood pressure 107/48, pulse 109, respirations 15. (R20) lethargic. Sending (R20) out to (Local hospital) for further evaluation. There is no documentation to support V28 resident representative was notified when R20 was sent to the hospital. The facility policy Acute Change in Condition revised 1/23/23 does not address the requirement to notify resident representative of condition change. On 11/1/23 at 1:00PM V1, Administrator stated It is my expectation we will always notify family or resident representative of any change in our resident's condition.
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Page 3 of 28
145862
11/01/2023
Hilltop Skilled Nsg & Rehab
910 West Polk Street Charleston, IL 61920
F 0644
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R37's Electronic Health Record documents R37 was admitted to the facility on [DATE]. R37's medical record does not include a level II PASARR screening. R37's OBRA (Omnibus Budget Reconciliation Act) Initial Screening dated 10/5/20 documents there is no reasonable basis to suspect R37 has a mental illness. R37's History and Physical dated 12/14/22 written by V25 Physician documents, Over the last several months (R37) has become paranoid and delusional to the point where he is now refusing to take any medications. Psychiatry recently evaluated him as having Paranoid Schizophrenia, but no medication is being used at this time. On 10/31/23 at 9:18 AM, V1 Administrator stated R37 did not require a level II PASRR when his original screening was completed. V1 stated R37 was diagnosed with Schizophrenia after being seen by his physician (V25) on 12/14/22. V1 stated it was added to his diagnosis list on 12/28/22. On 10/31/23 at 1:30 PM, V11 [NAME] President of Resident Services stated the facility should have obtained a new PASARR with a level II when the diagnosis of Schizophrenia was added.
Based on interview and record review, the facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) level I screening was completed for two (R24 and R37)of two residents reviewed for PASARR level I screenings with serious mental illnesses and prescribed anti-psychotic medication from a total sample list of 34 residents reviewed.
Findings Include: 1. R24's level I PASARR dated 7/1/19, documents that a level II PASARR is not required due to R24 not having a SMI (Severe Mental Illness) diagnosis upon admission to the facility on 7/2/19. R24's diagnosis sheet dated 11/20/20 documents a new diagnosis of Psychosis. R24's diagnosis sheet dated 1/5/23 documents a new diagnosis of Schizoaffecive disorder. R24's October 2023 physician order sheet documents Olanzapine 2.5 milligrams (mg) daily for schizoaffective disorder, Lorazepam 0.5mg for anxiety twice daily and Zoloft 25mg daily for depression. On 11/1/23 V19 Director of Operations said that another PASARR level one screening had not been obtained by the facility since the new psychiatric diagnoses and antipsychotic medication had been prescribed for R24 and that it should have been done.
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Page 4 of 28
145862
11/01/2023
Hilltop Skilled Nsg & Rehab
910 West Polk Street Charleston, IL 61920
F 0657
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to update a care plan with resident's significant weight loss for two of 16 residents (R11, R20) reviewed for care plans in the sample list of 34.
Findings include: The facility's Care Plan policy with a revision date of 1/11/23 documents, Purpose: To provide guidance to the facility in developing, implementing and communicating the individualized plan of care of residents. Policy: Our facility's Care Planning/Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. 1.) R11's Order Summary Report dated 11/1/23 documents diagnoses including Hemiplegia following a CVA (Cerebrovascular Accident), Dysphagia Oral Phase, Unspecified Protein-Calorie Malnutrition and Vitamin B12 Deficiency Anemia. R11's Weight Summary dated 11/1/23 documents R11's weight on 7/12/23 as 142.5 pounds, 8/14/23 as 134.0 pounds, 9/11/23 as 125.0 pounds and 10/16/23 as 120.0 pounds. That is a significant weight loss of 15.79 % (percent) from 7/12/23 to 10/16/23. V21 Dietician's Nutritional Risk assessment dated [DATE] documents R11 had a 13.7 % (percent) weight loss in three months and an 18.5 % weight loss in six months which is undesirable. V21 documents R11 was previously on a pureed diet with poor intake related to not liking the texture of the pureed food. V21 documents that R11's diet was changed to mechanical soft and R11's intake has improved some. V21 recommended adding ice cream for weight support. R11's Care Plan dated 1/3/23 documents a risk for altered nutrition and hydration related to Heart Disease, Hypertension, and refusing to eat at times. R11's Care Plan does not document the significant weight loss for the last six months. On 11/1/23 at 12:57 PM, V21 Dietician confirmed R11's significant weight loss and confirmed that should be on R11's Care Plan. 2.) R20's Care Plan revised 10/11/23 includes the following diagnoses: Type II diabetes Mellitus, Heart Disease, Anxiety, Dementia, Psychotic Disturbance, Mood Disorder, and Chronic Kidney Disease. R20's MDS (Minimum Data Set) dated 9/27/23 documents R20 is severely cognitively impaired. R20's weight tracking documents on 05/02/2023, (R20) weighed 168 lbs and on 10/23/2023, (R20) weighed 144 pounds which is a -14.29 % Loss There is no documentation to support (R20's) care plan was updated to reflect actual significant weight loss. On 10/30/23 at 11:00AM V12, Care Plan Coordinator stated When (R20) was determined to have experienced a significant weight loss it should have been updated on (R20's) care plan.
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Page 5 of 28
145862
11/01/2023
Hilltop Skilled Nsg & Rehab
910 West Polk Street Charleston, IL 61920
F 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to assist with/provide ADL (Activities of Daily Living) care for two of three residents (R11, R50) reviewed for ADLs in the sample list of 34.
Residents Affected - Few
Findings include: The facility's ADL Support policy with a revised date of 5/2/23 documents, Residents will be provided with care, treatment, and service as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with: a. Hygiene (bathing, dressing, grooming, and oral care). 1.) R11's Order Summary Report dated 11/1/23 documents diagnoses including Hemiplegia following a CVA (Cerebrovascular Accident), Other Idiopathic Peripheral Autonomic Neuropathy and [NAME] Matter Disease. R11's Minimum Data Set (MDS) dated [DATE] documents R11 has moderately impaired cognition and requires assistance with ADLs. On 10/30/23 at 9:47 AM, R11 was in bed and R11's fingernails on the right hand had a dark brown substance underneath them and they were long, extending over the end of the fingers approximately 1/8 to 1/4 inch. R11 has approximately 1/8 inch of facial hair outgrowth. On 10/31/23 at 10:32 AM, R11's fingernails were still long and still had a dark brown substance underneath the right hand fingernails. R11 also still had outgrowth of facial hair. On 11/1/23 at 8:52 AM, R11 was in bed and still not shaved and R11's fingernails were still long and appeared dirty underneath them. The right hand fingernails still had a dark brown substance underneath them. At this time R11 stated that R11 needs to be shaved and needs to have R11's nails cut. 2.) R50's Order Summary Report dated 10/30/23 documents diagnoses including Neurocognitive Disorder With Lewy Bodies and Unspecified Osteoarthritis. R50's MDS dated [DATE] documents R50 has severe cognitive impairment and requires extensive assistance of one staff for ADLs. On 10/31/23 at 12:05 PM, V6 and V7 Certified Nursing Assistants completed incontinence care for R50. During care R50 was pinching R50's arms with R50's long nails. V7 stated that R50's nails were sharp and V7 stated that V7 was afraid that R50 was going to tear R50's own skin by pinching R50's self. On 11/1/23 at 9:02 AM, V2 Director of Nursing stated males faces should be shaved as they desire but typically on their bath days and as needed throughout the week. V2 stated that the fingernails should be done on bath days and when needed except for Diabetic residents. For Diabetic residents the
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Page 6 of 28
145862
11/01/2023
Hilltop Skilled Nsg & Rehab
910 West Polk Street Charleston, IL 61920
F 0677
nurses need to assist with those. V2 stated that V2 expects the resident's fingernails to be clean.
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
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Page 7 of 28
145862
11/01/2023
Hilltop Skilled Nsg & Rehab
910 West Polk Street Charleston, IL 61920
F 0686
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Level of Harm - Minimal harm or potential for actual harm
Based on observation, interview, and record review the facility failed to provide pressure ulcer treatments and relieve pressure while up in the wheelchair for one (R18) of four residents reviewed for pressure ulcers on the sample list of 34.
Residents Affected - Few
Findings include: On 10/31/23 at 2:00 PM, R18 had a dime sized pressure ulcer to the left upper thigh. R18's wound assessment and plan dated 10/18/23 documents R18's wound to the left upper thigh as a pressure injury measuring 0.5 centimeters by 1.1 centimeters by 0.1 centimeters. On 10/30/23 from 12:12 PM to 12:29 PM, R18 was sitting in the dining room. R18 complained multiple times that he was sliding down in the wheelchair. R18 was noted to be sitting on a pressure relief cushion. A mechanical lift sling was positioned under R18's buttocks and on top of the pressure relief cushion. The sling was noted to be bunched in places. V6 Certified Nurse's Assistant assisted R18 with re-positioning in the wheelchair. On 11/01/23 at 2:51 PM, V6 stated she helped R18 with repositioning in the dining room on 10/30/23. V6 stated the mechanical lift sling lying on top of the pressure relief cushion did cause sliding of the sling. The facility's mechanical lift policy with a revision date of 1/23/23 documents instructions to remove the mechanical lift sling from underneath the resident after transferring the resident. On 11/1/23 at 11:40 AM, V19 Director of Operations stated she thinks the mechanical lift sling is supposed to be removed after transfer for the prevention of pressure. At 11:50 AM, V19 stated she called the person who made the policy and they have now amended the policy a few minutes ago to state that they only remove the sling when transferring to bed. V19 verified that the amended policy was not changed until it was questioned and that it used to say to remove the sling after transfers. R18's treatment record documents an order dated 9/28/23 to 10/3/23 to apply medical honey with calcium alginate to left posterior medial thigh topically one time a day. This treatment record does not document that the treatment was completed on 10/1/23, 10/2/23, or 10/3/23. R18's treatment record documents an order dated 10/3/23 to 10/6/23 to apply medical honey with calcium alginate to left posterior medial thigh topically one time a day. This treatment record does not document that the treatment was completed on 10/5/23 or 10/6/23. R18's treatment record documents an order dated 10/6/23 to 10/18/23 to apply medical honey with calcium alginate to left posterior medial thigh topically one time a day. This treatment record does not document that the treatment was completed on 10/11/23. R18's treatment record documents an order dated 10/18/23 to apply medical honey with calcium alginate to left posterior medial thigh topically one time a day. This treatment record does not document that the treatment was completed on 10/25/23, 10/26/23, 10/27/23 or 10/29/23. On 11/1/23 at 3:00 PM, V19 stated in regards to the days that R18's treatment are not signed off
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Page 8 of 28
145862
11/01/2023
Hilltop Skilled Nsg & Rehab
910 West Polk Street Charleston, IL 61920
F 0686
(10/1/23, 10/2/23, 10/3/23, 10/5/23, 10/6/23, 10/11/23, 10/25/23, 10/26/23, 10/27/23 and 10/29/23) that, If they aren't signed off that means that they weren't done.
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
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Page 9 of 28
145862
11/01/2023
Hilltop Skilled Nsg & Rehab
910 West Polk Street Charleston, IL 61920
F 0689
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Level of Harm - Actual harm
Residents Affected - Few
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide adequate supervision to prevent a resident from leaving the building resulting in a fall outside on the sidewalk (R52) and failed to remove a mechanical lift sling from underneath a resident to prevent sliding in the wheelchair (R18) for two of eight residents (R52, R18) reviewed for accidents in the sample list of 34. This failure resulted in R52 exiting the building unaccompanied and falling resulting in abrasions to R52's face, hand and knee and a bruise to R52's face.
Findings include: The facility's Accidents and Incidents policy with a revised date of 9/7/23 documents, Purpose: To provide staff with guidelines for investigating, reporting, and recording Accidents and incidents. Policy: All accidents/incidents involving a resident shall require an incident report. The interdisciplinary team (IDT) will complete an investigation to determine root cause and implement appropriate interventions. 1.) R52's Order Summary Report dated 10/31/23 documents diagnoses including Orthostatic Hypotension, Personal History of Transient Ischemic Attack, Other Specified Disorders of the Brain, Vascular Dementia, Adjustment Disorder With Depressed Mood, Suicidal Ideations, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Auditory Hallucinations, Other Seizures, Mild Cognitive Impairment of Uncertain or Unknown Etiology and Repeated Falls. This Order Summary documents an order for an electronic alert device placement every shift for monitoring and an order to check the function of the device every shift with an order date of 10/10/23. R52's Nurse's Note dated 9/5/23 at 9:27 AM documents R52 was exit seeking and electronic alert device was placed to R52's left leg. This note documents R52 stated R52 wanted to walk outside. R52's Nurse's Note dated 9/6/23 at 8:43 AM documents R52 removed the electronic alert device at breakfast and Social Services was made aware. R52's Nurse's Note dated 10/10/23 at 9:47 AM documents that staff noticed R52's electronic alert device sitting on the bedside stand. This note documents R52 stated R52 bit it off of R52's wrist. This note then documents the Social Services Director was able to talk R52 into putting the electronic alert device back on R52's wrist. R52's Nurse's Note dated 10/26/23 at 2:00 PM documents the nurse was alerted by staff that R52 was outside on the ground by the smoking area. R52 was non-compliant with fall alarm and electronic alert device and was walking without assistance resulting in a fall. Assessment showed abrasion to the right knee, a bruise to the left middle back, a skin tear to the right great toe and right hand, and bruising and an abrasion to the left temple and cheek. R52's Minimum Data Set (MDS) dated [DATE] documents R52 is moderately cognitively impaired and requires assistance of one staff member for ambulation. This MDS documents that R52's balance is not steady when walking, that R52 can only be steady with staff assist. R52's Care Plan dated 9/5/23 documents R52 has a potential risk of elopement, cognitive deficit,
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Page 10 of 28
145862
11/01/2023
Hilltop Skilled Nsg & Rehab
910 West Polk Street Charleston, IL 61920
F 0689
Level of Harm - Actual harm
Residents Affected - Few
exit seeking behavior (with purpose to leave), history of elopement, history of wandering, repetitive pacing (ambulatory), walks or wheels about aimlessly w/o (without) purpose. This Care Plan has interventions dated 9/5/23 to place an electronic sensor device to alert staff of exit attempt (or if unavailable place on 1:1 observation), check placement device, check battery function and evaluate effectiveness. Monitor whereabouts regularly, recognize any unsafe conditions or escalating patterns and respond to any alarm activation promptly. On 10/30/23 at 9:55 AM, R52 was in R52's bed sleeping. R52 had a bruise on R52's left eye. There was a mat on the floor and a pressure alarm on the bed. On 10/30/23 at 3:01 PM, R52 was in R52's wheelchair outside smoking. There was a staff member outside with R52. On 10/31/23 at 12:35 PM, R52 was in R52's bathroom with the door open. R52's wheelchair was sitting outside of the bathroom door and the pressure alarm was sitting in the wheelchair not sounding. V6 Certified Nursing Assistant was notified and immediately went to assist R52. V6 stated that R52 turns off the pressure alarm so they do not know when R52 gets up. R52's Fall report dated 10/26/23 documents the nurse was notified of R52 being found on the ground face first. Nurse assessed R52 and addressed skin impairments and applied first aid. Nurse located electronic alert device and placed it to R52's right ankle and all staff were notified to check the placement of the electronic alert device. On 10/31/23 at 3:05 PM, V26 Certified Nursing Assistant stated that when R52 fell on [DATE] V26 was the only CNA working on R52's hall and V26 did not see R52 leave. V26 stated that R52 removed the electronic alert device and left it in R52's room and rolled the wheelchair to the front door, stood up and pushed the button to turn off the door alarm and walked out the door. V26 stated that R52 walked around the building to the smoking area and R52's shoe slipped off when R52 got to the grass area and R52 fell face first into the concrete. V26 stated that another resident's family was outside with that resident and found R52. V26 stated no one in the facility knew that R52 had gotten outside alone. V26 stated that if that family hadn't found R52 who knows how long R52 would have laid out there. On 11/1/23 at 2:52 PM, V2 Director of Nursing stated regarding R52's fall on 10/26/23 that V2 can't speak to the fact of whether R52 had the electronic alert device on or not as V2 was not in the building at the time of the fall. V2 confirmed that R52 exited out the front door and got out without anyone knowing R52 left the building. V2 confirmed R52 should not have been outside by R52's self. V2 confirmed that R52 has removed the electronic alert device multiple times and they replace it when they find it. On 11/1/23 at 2:58 PM, V1 Administrator confirmed that another resident's family found R52 outside after R52 had gotten out of the building and fell. V1 confirmed that R52's current black eye is from the fall on 10/26/23 and V1 confirmed that R52 was not supposed to be outside alone. On 11/1/23 at 3:04 PM, R52 stated on 10/26/23 when R52 fell, R52 went out the front door of the facility and walked through the parking lot to the smoking area and when R52 got to the grass area R52's shoe got caught on the grass and R52 tripped and fell and hit R52's face on the concrete sidewalk. 2.) R18's care plan with a revision date of 10/30/23 documents R18 is at risk for falls and injuries related to impaired balance and mobility. This care plan includes an intervention for a mechanical
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11/01/2023
Hilltop Skilled Nsg & Rehab
910 West Polk Street Charleston, IL 61920
F 0689
lift.
Level of Harm - Actual harm
On 10/30/23 from 12:12 PM to 12:29 PM, R18 was sitting in the dining room. R18 complained multiple times that he was sliding down in the wheelchair. R18 was noted to be sitting on a pressure relief cushion. A mechanical lift sling was positioned under R18's buttocks and on top of the pressure relief cushion. The sling was noted to be bunched in places. V6 Certified Nurse's Assistant assisted R18 with re-positioning in the wheelchair.
Residents Affected - Few
On 11/01/23 at 2:51 PM, V6 stated she helped R18 with repositioning in the dining room on 10/30/23. V6 stated the mechanical lift sling lying on top of the pressure relief cushion did cause sliding of the sling. The facility's mechanical lift policy with a revision date of 1/23/23 documents instructions to remove the mechanical lift sling from underneath the resident after transferring the resident. On 11/1/23 at 11:40 AM, V19 Director of Operations stated she thinks the mechanical lift sling is supposed to be removed after transfer for the prevention of pressure. When asked if it was also to prevent residents from slipping out of the wheelchair, V19 stated yes. At 11:50 AM, V19 stated she called the person who made the policy and they have now amended the policy a few minutes ago to state that they only remove the sling when transferring to bed. V19 verified that the amended policy was not changed until it was questioned and that it used to say to remove the sling after transfers.
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Page 12 of 28
145862
11/01/2023
Hilltop Skilled Nsg & Rehab
910 West Polk Street Charleston, IL 61920
F 0690
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to perform complete incontinence care for one of two residents (R50) reviewed for incontinence care in the sample list of 34.
Findings include: The facility's Incontinence Care Policy with a revised date of 5/16/22 documents, All incontinent residents will receive incontinence care in order to keep skin clean, dry and free of irritation and/or odor. Incontinence care will be provided as required. Wash all soiled skin areas and dry very well, especially between skin folds; changing gloves and performing hand hygiene as required to prevent cross-contamination. R50's Order Summary Report dated 10/30/23 documents diagnoses including Neurocognitive Disorder With Lewy Bodies and Unspecified Osteoarthritis. R50's MDS dated [DATE] documents R50 has severe cognitive impairment and requires extensive assistance of one staff for ADLs. On 10/31/23 at 12:05 PM, V6 and V7 Certified Nursing Assistants completed incontinence care for R50. V6 washed R50's front side and they rolled R50 onto R50's side and removed the urine saturated incontinence brief from underneath R50. V6 washed R50's right buttocks and anal area and dried the same area. V6 and V7 rolled R50 back to the other side and placed a clean incontinence brief underneath R50. V6 applied a barrier cream to R50 and closed the brief and covered R50 with the blankets. V6 did not wash R50 left buttocks even though the incontinence brief was saturated with urine and R50 had been laying in bed for over an hour and a half. On 11/1/23 at 8:40 AM, V2 Director of Nursing stated that V2 expects staff to wash the entire buttocks of the residents not just one side.
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Page 13 of 28
145862
11/01/2023
Hilltop Skilled Nsg & Rehab
910 West Polk Street Charleston, IL 61920
F 0692
Provide enough food/fluids to maintain a resident's health.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to implement nutritional interventions for a resident with significant weight loss for one of four residents (R11) reviewed for weight loss in the sample list of 34.
Residents Affected - Few
Findings include: The facility's Weight Assessment and Intervention policy with a reviewed date of 11/2/21 documents, The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. Interventions for undesirable weight loss shall be based on careful consideration of the following: choices, preferences, nutrition and hydration needs, functional factors, environmental factors, chewing and swallowing abnormalities, medications, supplemental feeding and end of life decisions. R11's Order Summary Report dated 11/1/23 documents diagnoses including Dysphagia Oral Phase, Unspecified Protein-Calorie Malnutrition, Gastro-Esophageal Reflux Disease, Hypokalemia and Vitamin B12 Deficiency Anemia. R11's Weight Summary dated 11/1/23 documents R11's weight on 7/12/23 as 142.5 pounds, 8/14/23 as 134.0 pounds, 9/11/23 as 125.0 pounds and 10/16/23 as 120.0 pounds. That is a significant weight loss of 15.79 % (percent) from 7/12/23 to 10/16/23. On 11/1/23 at 12:44 PM, R11 was in bed and had just received R11's lunch tray. R11 had ground meat and mashed potatoes with gravy and a chocolate brownie. R11 had built up silverware and was feeding R11's self. There was no nutritional supplement on R11's lunch tray. R11's Nutritional Risk assessment dated [DATE] by V21 Dietician documents R11 had a significant weight loss which was undesired. V21 recommended adding ice cream twice a day at lunch and dinner. R11's diet tray card does not document the recommendation of ice cream at lunch and dinner. On 11/1/23 at 12:48 PM, V22 Dietary Manager stated if the Dietician puts in a recommendation that it goes to nursing and they put the order in the computer system and then give V22 a diet communication card. Then V22 puts the recommendation on the tray card. V22 stated that it should happen within 24-48 hours. V22 stated V22 would assume R11 should be getting ice cream at lunch and dinner. V22 confirmed that ice cream was not on R11's tray card. On 11/1/23 at 12:57 PM, V21 Dietician stated when V21 writes a recommendation V21 expects the order to be put in place within 48 hours. V21 stated R11 should be getting ice cream at lunch and dinner. V21 stated that V21 can see in the computer system that the order has not been put in place. V21 stated V21 is going to send another recommendation to nursing for the addition of the ice cream for R11. On 11/1/23 at 3:15 PM, V13 Corporate Nurse provided documentation that the Nurse Practitioner decided to order 4 oz (ounces) of a protein shake instead of the ice cream on 10/16/23. R11's Medication Administration Record dated 10/1/23 through 10/31/23 does not document an order
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Hilltop Skilled Nsg & Rehab
910 West Polk Street Charleston, IL 61920
F 0692
for the protein shake. R11's medical record contains no documentation that R11 received any nutritional supplement after V21 Dietician recommended one on 10/11/23.
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
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11/01/2023
Hilltop Skilled Nsg & Rehab
910 West Polk Street Charleston, IL 61920
F 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm or potential for actual harm
Based on observation, interview and record review the facility failed to provide oxygen therapy as ordered and failed to change oxygen tubing weekly for one (R17) of one residents reviewed for oxygen therapy from a total sample list of 34 residents.
Residents Affected - Few
Findings include: The facility Oxygen Administration policy dated 3/17/22 documents that it is the responsibility of the charge nurse to ensure that residents who have an order for oxygen are receiving it properly. Additionally, the tubing will be changed and dated weekly. R17's undated diagnosis sheet documents Acute and Chronic Respiratory Failure, Chronic Pulmonary Edema and Chronic Obstructive Pulmonary Disease. R17's October physician order sheet documents oxygen to be administered at 2-4 liters per nasal cannula to maintain oxygen above 90 percent. On 10/30/23 at 11:58AM, R17 was wearing oxygen while working a puzzle. R17's portable tank was empty and the nasal cannula tubing was dated 10/23/23, confirmed by V2 Director of Nursing. On 11/1/23 at 11:30 AM, R17's oxygen was running at three liters per nasal cannula with the tubing dated 10/23/23. On 11/1/23 at 11:40AM, V4 Licensed Practical Nurse stated that R17 wears oxygen at all times and that the tubing is supposed to be changed weekly.
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11/01/2023
Hilltop Skilled Nsg & Rehab
910 West Polk Street Charleston, IL 61920
F 0700
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Based on observation, interview, and record review the facility failed to assess the risk for entrapment for the use of a bed rail for one of one resident (R18) reviewed for bed rails on the sample list of 34.
Findings include: On 10/31/23 at 9:12 AM, R18 was lying in bed. The bed was positioned along the wall. A half bed rail was elevated on R18's right hand side of the bed. R18's medical record did not contain documentation that R18 was assessed for the risk of entrapment for the use of the bed rail. On 11/01/23 at 10:35 AM, V1 Administrator stated there is not an assessment for the use of R18's bed rail.
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11/01/2023
Hilltop Skilled Nsg & Rehab
910 West Polk Street Charleston, IL 61920
F 0732
Post nurse staffing information every day.
Level of Harm - Potential for minimal harm
Based on observation, interview and record review the facility failed to post daily staffing. This failure has the potential to affect all 61 residents residing in facility.
Residents Affected - Many
Findings include: The facility's Long-Term Care Facility Application for Medicare and Medicaid dated 11/1/23 documents 61 residents reside in facility. On 10/30/23 upon entry into the facility there was no posted staffing located anywhere in the lobby or office areas. On 10/31/23 at 9:00 AM, there is still no posted staffing located anywhere in the lobby or office areas of the facility. On 11/1/23 at 1:30 PM, V1 Administrator confirmed the daily staffing is not posted. V1 stated V1 doesn't know why it's not posted.
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11/01/2023
Hilltop Skilled Nsg & Rehab
910 West Polk Street Charleston, IL 61920
F 0758
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Some
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Based on interview and record review the facility failed to assess the need for Psychotropic medications for five of five residents (R52, R9, R50, R18, R24) reviewed for unnecessary medications in the sample list of 34.
Findings include: The facility's undated Psychotropic Medication Protocol documents, Purpose: To provide guidance to facility staff in the implementation, monitoring and gradual dose reductions of psychotropic medications. Initiate GDR (Gradual Dose Reduction) monitoring flow sheet. Within 30 days of Initiation Discuss at weekly risk meeting, potential GDR evaluation (Complete assessment and update GDR monitoring flow sheet), AIMS (Abnormal Involuntary Movement Scale) (if antipsychotic). Quarterly Initiate potential GDR (complete assessment and update GDR monitoring flow sheet). 1.) R52's Order Summary Report dated 10/31/23 documents diagnoses including Generalized Anxiety Disorder, Bipolar Disorder, Vascular Dementia, Adjustment Disorder with Depressed Mood, Suicidal Ideation, Auditory Hallucinations, Mild Cognitive Impairment and Major Depressive Disorder. R52's Order Summary Report dated 10/31/23 documents orders for Duloxetine HCL (Hydrochloride) 60 mg (milligrams) every morning and at bedtime for Depression with a start date of 8/9/23. Hydroxyzine HCL 10 mg three times a day for Anxiety with a start date of 10/12/23. Nortriptyline HCL 50 mg at bedtime for Depression with a start date 8/14/23. R52's medical record does not contain an assessment for the use of the Hydroxyzine for Anxiety. On 11/1/23 at 1:29 PM, V13 Regional Nurse confirmed there was no psychotropic medication assessment for the Hydroxyzine for the Depression for R52. 2.) R9's Order Summary Report dated 10/31/23 documents diagnoses including Borderline Personality Disorder, Post Traumatic Stress Disorder, Major Depressive Disorder, Mild Intellectual Disabilities, Mood Disorder, Suicidal Ideation, Adjustment Disorder with Mixed Disturbance of Emotions and Conduct and Generalized Anxiety Disorder. R9's Order Summary Report dated 10/31/23 documents order for Aripiprazole ER (Extended Release) (antipsychotic) prefilled syringe 400 mg (milligrams) one dose every 28 days for Depression and Anxiety with a start date of 10/15/23. Benzotropine Mesylate (anticholinergic) 0.5 mg twice a day for Depression with a start date of 10/16/23. Duloxetine HCL (antidepressant) 60 mg once a day for Major Depressive Disorder with a start date of 10/15/23. Hydroxyzine HCL (antihistamine) 25 mg three times a day for Generalized Anxiety Disorder with a start date of 10/14/23. Lamictal (anticonvulsant) 150 mg in the morning for Borderline Personality Disorder with a start date of 10/15/23. Lamictal 200 mg at bedtime for Borderline Personality Disorder with a start date of 10/14/23. Mirtazapine (antidepressant) 15 mg at bedtime for Major Depressive Disorder with a start date of 10/14/23. R9's medical record does not contain an assessment for the use of Benzotropine Mesylate for the Depression or the Lamictal for the Borderline Personality Disorder for R9.
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145862
11/01/2023
Hilltop Skilled Nsg & Rehab
910 West Polk Street Charleston, IL 61920
F 0758
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Some
On 11/1/23 at 1:29 PM, V13 confirmed there were no psychotropic medication assessments for the Benzotropine or Lamictal for R9. 3.) R50's Order Summary Report dated 10/30/23 documents diagnoses including Neurocognitive Disorder with Lewy Bodies, Unspecified Psychosis, Insomnia, Restlessness and Agitation and Major Depressive Disorder. R50's Order Summary Report dated 10/30/23 documents orders for Paroxetine (Selective Serotonin Reuptake Inhibitor) HCL 10 mg in the morning for Major Depressive Disorder with a start date of 3/3/23. Quetiapine Fumarate (antipsychotic) 25 mg twice a day for Psychosis with a start date of 5/5/23. Trazadone HCL 50 mg at bedtime for Major Depressive Disorder with a start date of 4/20/23. R50's medical record does not contain an assessment for the use of Paroxetine and Trazadone for Major Depressive Disorder for R50. On 11/1/23 at 1:29 PM, V13 confirmed there were no psychotropic medication assessments for the Paroxetine or Trazadone for R50. 4.) R18's Medication Administration Record dated 10/1/23 to 10/31/23 documents an order dated 4/20/23 for Bupropion 150 milligrams (antidepressant) one tablet once a day for depression 4/20/2023. R18's medical record does not include an assessment for the use of Bupropion. On 11/1/23 at 8:00 AM, V10 Chief Operating Officer stated that the facility did not obtain initial assessments for psychotropic medications.5.) R24's October 2023 physician order sheet documents Olanzapine 2.5milligrams (mg) daily for schizoaffective disorder, Lorazepam 0.5mg for anxiety twice daily and Zoloft 25mg daily for depression. R24's medical record did not contain initial assessments for the use of Olanzapine, Lorazepam and Zoloft. On 11/1/23 at 8:45AM, V13 Corporate Nurse stated that there are no initial assessments for psychotropic medications for R24. On 11/1/23 at 8:00AM, V10 Chief Operating Officer stated that the facility did not obtain initial assessments for psychotropic medications and that they would be changing their practice.
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11/01/2023
Hilltop Skilled Nsg & Rehab
910 West Polk Street Charleston, IL 61920
F 0761
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Based on observation, interview and record review the facility failed to securely store a schedule four medication and failed to dispose of undated insulin for three (R4, R47 and R213) of three residents reviewed for medication storage from a total sample list of 34 residents.
Findings include: The facility Medication Storage policy dated 7/11/21 documents that all drugs will be stored in a safe, secure and orderly manner in accordance with state and federal regulations. Additionally, schedule 2-4 controlled medications will be stored in separately locked, permanently affixed compartments. Access to controlled medication is separate from access to non-controlled medication. The facility provided insulin drug manufacturer instructions document that multidose, Lantus and Humalog Insulin vials must be disposed 28 days after opened. The facility provided insulin drug manufacturer instructions document that a multidose, Levemir Insulin vial must be disposed 42 days after opened. On 10/30/23 at 3:51PM, V5 Registered Nurse (RN) confirmed that R4's open Lantus Insulin, nor open Humalog Insulin were dated with an opened on date. On 10/30/23 at 3:51PM, V5 RN confirmed that R47's Levemir Insulin was not dated with an opened on date. On 10/30/23 at 3:55PM, V5 RN stated that all insulins are to be dated when opened so that they are not used after their disposal date. On 10/31/23 at 10:24AM, the Core Medication Room refrigerator did not have a lock on the refrigerator and the refrigerator contained Lorazepam (Schedule IV Controlled Medication) for R213, confirmed by V5 RN. On 11/1/23 at 12:15PM, V10 Chief Operating Officer confirmed that all Insulin should be dated upon opening. On 11/1/23 at 1:20PM, V13 Corporate Nurse said that Lorazepam is supposed to be locked behind two locks.
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11/01/2023
Hilltop Skilled Nsg & Rehab
910 West Polk Street Charleston, IL 61920
F 0812
Level of Harm - Minimal harm or potential for actual harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Based on observation, interview, and record review the facility failed to prepare and distribute food under sanitary conditions. This failure has the potential to affect all 61 residents residing in the facility.
Residents Affected - Many
Findings include: On 10/31/23 at 10:57 AM, V23 [NAME] pureed a pork loin. V23 was wearing a ball cap. V23's hair stuck out of the edges of the ball cap. V23 had a full beard and and was not wearing a face covering over his beard. On 10/31/23 at 12:11 PM, V23 was serving lunch and was not wearing a face covering or a ball cap. On 11/01/23 at 1:28 PM, V22 Dietary Manager stated that V23 should have had his beard covered when cooking and serving food on 10/31/23. The facility's Long Term Care Application for Medicare and Medicaid form dated 11/1/23 signed by V1 Administration documents there are 61 residents residing in the facility.
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11/01/2023
Hilltop Skilled Nsg & Rehab
910 West Polk Street Charleston, IL 61920
F 0867
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Many
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Based on interview and record review the facility failed to develop, implement and maintain an ongoing quality assurance performance improvement program over the past 12 months. This failure has the potential to affect all 61 residents of the facility.
Findings include: The Long-Term Care Facility Application For Medicare and Medicaid dated 11/1/23 and signed by V1 Administrator documents 61 residents reside in the facility. The facility provided Quality Assurance Policy dated 7/20/22 documents that the Quality Assurance Performance Improvement (QAPI) Committee oversees implementation of the QAPI plan, which is the written component of describing the specifics of the QAPI program, how the facility will conduct its QAPI functions and the activities of the QAPI committee. On 11/1/23 at 11:35AM, V1 stated that she was not aware of any performance improvement projects that had been developed by the quality committee over the past year. Nor was any performance project implemented with the front line staff and evaluated by the quality committee. No tracking and trending of performance goals, monitoring for performance improvement, nor documentation of performance improvement was provided during this survey.
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145862
11/01/2023
Hilltop Skilled Nsg & Rehab
910 West Polk Street Charleston, IL 61920
F 0868
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Level of Harm - Minimal harm or potential for actual harm
Based on interview and record review the facility failed to hold quarterly quality improvement meetings over the past 12 months. This failure has the potential to affect all 61 residents of the facility.
Residents Affected - Many
Findings include: The Long-Term Care Facility Application For Medicare and Medicaid dated 11/1/23 and signed by V1 Administrator documents 61 residents reside in the facility. The facility provided Quality Assurance Policy dated 7/20/22 documents that the administrator is responsible for insuring that the facility's quality program complies with federal, state and local regulatory requirements. On 11/1/23 at 11:54AM, V1 Administrator stated that no quality information could be provided prior to August of 2023, including meeting minutes. On 11/1/23 at 12:00PM, V10 Chief Operating Officer confirmed that no quality information could be located prior to August 2023.
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Page 24 of 28
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11/01/2023
Hilltop Skilled Nsg & Rehab
910 West Polk Street Charleston, IL 61920
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm or potential for actual harm
b.) The facility's Incontinence Care Policy with a revised date of 5/16/22 documents, All incontinent residents will receive incontinence care in order to keep skin clean, dry and free of irritation and/or odor. Incontinence care will be provided as required. Wash all soiled skin areas and dry very well, especially between skin folds; changing gloves and performing hand hygiene as required to prevent cross-contamination.
Residents Affected - Many
On 10/31/23 at 12:05 PM, V6 and V7 Certified Nursing Assistants (CNA) prepared supplies to perform incontinence care for R50. V6 washed V6's hands and donned a pair of gloves. V7 closed the door and pulled the privacy curtain then donned a pair of gloves without performing hand hygiene. V6 and V7 opened R50's incontinence brief and V6 put a wash cloth in a basin of water and sprayed perineal wash on the wash cloth and washed the front creases of R50. V6 proceeded to get another wash cloth and continue to clean the front perineal area of R50. R50's perineal area was reddened. After finishing R50's front side they rolled R50 onto R50's side and without changing gloves or performing hand hygiene V6 got another wash cloth wet and sprayed with perineal wash and proceeded to wash the right buttock. V6 got another wash cloth and washed the anal area then dried with a dry wash cloth. V7 removed the urine saturated incontinence brief and handed it to V6 and V6 threw it in the garbage can. Without changing gloves or performing hand hygiene V6 put a clean draw sheet underneath R50 and laid a clean incontinence brief next to R50. V6 then applied a barrier cream to R50's back side and removed V6's gloves and washed V6's hands and donned new gloves. V7 still donned the same pair of gloves. They put the clean brief under R50 and rolled R50 to straighten the brief and draw sheet. V7 touched the clean brief and clean draw sheet and R50 and R50's bed linens with the same pair of gloves that V7 removed the saturated incontinence brief with. V6 then applied barrier cream to R50's front perineal area and removed V6's gloves. V7 closed the incontinence brief. They repositioned R50 in bed then performed hand hygiene. On 11/1/23 at 8:40 AM, V2 Director of Nursing stated that the CNAs should be changing their gloves between clean and dirty. They should change gloves after touching anything dirty before touching the resident. V2 confirmed the CNAs should have changed their gloves after removing the urine saturated incontinence brief. A. Based on record review and interview the facility failed to initiate a water management program. This failure has the potential to affect all 61 residents residing at the facility. B. Based on observation, interview and record review the facility failed to prevent potential cross contamination during incontinence care for one of two residents (R50) reviewed for incontinence care in the sample list of 34.
Findings Include: a.) The facility's Long-Term Care Facility Application for Medicare and Medicaid dated 11/1/23 documents 61 residents reside in facility. The facility's policy Legionella Water Management Program last revised July 2017 (not reviewed annually) states Our facility is committed to the prevention, detection, and control of water-borne contaminants, including Legionella. The water management team will consist of at least the following personnel: Infection preventionist, the Administrator, the Medical Director, the Director of Maintenance, the Director of Environmental Services. The purpose of the water management program is to
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145862
11/01/2023
Hilltop Skilled Nsg & Rehab
910 West Polk Street Charleston, IL 61920
F 0880
Level of Harm - Minimal harm or potential for actual harm
identify areas in the water system where Legionella bacteria can grow and spread, and to reduce the risk of Legionnaire's Disease. On 10/31/23 at 3:00PM V1, Administrator stated I will be honest with you we do not currently have a water management program in place. All I have is the policy.
Residents Affected - Many
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11/01/2023
Hilltop Skilled Nsg & Rehab
910 West Polk Street Charleston, IL 61920
F 0883
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Level of Harm - Minimal harm or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to offer/administer Pneumococcal vaccines for four residents (R23, R29, R8, R49) of five residents reviewed for Vaccines in a sample list of 34.
Residents Affected - Some
Findings include: The facility's Infection Control policy revised 5/21/22 states Each resident will be offered the influenza, pneumonia, and SARs-Co-V2 (COVID) vaccines as directed per CDC (Centers for Disease Control) guidelines, unless medically contraindicated. This shall be documented. 1. R23's Minimum Data Set (MDS) dated [DATE] documents R23 was not offered and did not receive the pneumococcal vaccine. There is no consent or refusal of the pneumococcal vaccine included on R23's electronic medical record. The immunization tracking included in R23's medical records does not document R23 received pneumococcal vaccine(s) according to current guidelines. 2. R29's Minimum Data Set (MDS) dated [DATE] documents R29 was not offered and did not receive the pneumococcal vaccine. There is no consent or refusal of the pneumococcal vaccine included on R29's electronic medical record. The immunization tracking included in R29's medical records does not document R29 received pneumococcal vaccine(s) according to current guidelines. 3. R8's Minimum Data Set (MDS) dated [DATE] documents R8 was not offered and did not receive the pneumococcal vaccine. There is no consent or refusal of the pneumococcal vaccine included on R8's electronic medical record. The immunization tracking included in R8's medical records does not document R8 received pneumococcal vaccine(s) according to current guidelines. 4. R49s Minimum Data Set (MDS) dated [DATE] documents R49 was not offered and did not receive the pneumococcal vaccine. There is no consent or refusal of the pneumococcal vaccine included on R49s electronic medical record. The immunization tracking included in R49's medical records does not document R49 received pneumococcal vaccine(s) according to current guidelines. On 10/30/23 at 2:30PM V12 Infection Preventionist/Care Plan Coordinator stated If there isn't a consent or refusal for a pneumonia or COVID vaccine in the miscellaneous section of the resident's chart or documentation in the immunization section of the resident's chart then the resident didn't get the vaccine.
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Page 27 of 28
145862
11/01/2023
Hilltop Skilled Nsg & Rehab
910 West Polk Street Charleston, IL 61920
F 0887
Level of Harm - Minimal harm or potential for actual harm
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Based on record review and interview the facility failed to offer/administer Sars-Co-V2 (COVID) vaccines for four residents (R23, R29, R8, R49) of five residents reviewed for vaccines in a sample list of 34.
Residents Affected - Some
Findings include: The facility's Infection Control policy revised 5/21/22 states Each resident will be offered the influenza, pneumonia, and COVID vaccines as directed per CDC (Center for Disease Control) guidelines, unless medically contraindicated. This shall be documented. COVID-19 Vaccines for Long-term Care Residents Updated Sept. 25, 2023 documents: CDC recommends everyone aged 5 years and older, including people who live and work in Long-term Care (LTC) settings, get 1 updated COVID-19 vaccine. People who are moderately or severely immunocompromised can get additional updated COVID-19 vaccines. Learn more about additional doses. People who live in LTC settings must give consent, or agree to getting a COVID-19 vaccine. 1. There is no consent or refusal of the current COVID booster included on R23's electronic medical record. The immunization tracking included in R23's medical records does not document R23 received a COVID booster according to current guidelines. 2. There is no consent or refusal of the the current COVID booster included on R29's electronic medical record. The immunization tracking included in R29's medical records does not document R29 received the current COVID booster according to current guidelines. 3. There is no consent or refusal of the current COVID booster included on R8's electronic medical record. The immunization tracking included in R8's medical records does not document R8 received the current COVID booster according to current guidelines. 4. There is no consent or refusal of the current COVID booster included on R49's electronic medical record. The immunization tracking included in R49's medical records does not document R49 received the current COVID booster according to current guidelines. On 10/30/23 at 2:30PM V12 Infection Preventionist/Care Plan Coordinator stated, If there isn't a consent or refusal for a pneumonia or COVID vaccine in the miscellaneous section of the residents chart or documentation in the immunization section of the resident's chart then the resident didn't get the vaccine.
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Back to topCitations
21 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
F580 - Notification of Changes
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F692 - Assisted nutrition and hydration
Provide enough food/fluids to maintain a resident's health.
F700 - Bed Rails
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
F732 - Nurse Staffing Information
Post nurse staffing information every day.
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F867 - Program feedback, data systems and monitoring
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
F868 - Quality assessment and assurance
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
F887 - Infection control
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F644 - Coordination
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F883 - Influenza and pneumococcal immunizations
Develop and implement policies and procedures for flu and pneumonia vaccinations.
F677 - A resident who is unable to carry out activities of daily living receives
Provide care and assistance to perform activities of daily living for any resident who is unable.
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the November 1, 2023 survey of HILLTOP SKILLED NSG & REHAB?
This was a inspection survey of HILLTOP SKILLED NSG & REHAB on November 1, 2023. The surveyor cited 21 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at HILLTOP SKILLED NSG & REHAB on November 1, 2023?
Yes, 21 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.