Hilltop Park Rehabilitation And Care Center

F-F580 - Notify of Changes (Injury/Decline/Room, Etc.)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 25 675988 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675988 B. Wing 02/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hilltop Park Rehabilitation and Care Center 970 Hilltop Dr Weatherford, TX 76086

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Resident #1 was sent to Hospital on 12/30/24. On 1/3/25 due to HHSC entrance of the facility that there was

a complaint of resident #1. Facility began to review any other residents with G-tubes no other residents with Level of Harm - Immediate a G-tube remains in the facility and/or changes in condition, that would result with any required changes of jeopardy to resident health or condition and physician notification. safety oThe Charge nurses reviewed for any other changes of condition, and none were identified on 1/3/25 by Residents Affected - Some oversight from the DON.

The underlying cause is the facility failed to ensure the Physician was notified when a resident experienced a change in condition.

All residents could have been affected by this alleged deficient practice.

oOn 1/3/2025 - Verbal policy review of Policy of Change of Condition or Status/SBAR change of condition was provided by the Corporate Quality Improvement Nurse to DON/ADON, (The policy was reviewed, and verbal comprehension was acknowledged via Q&A and discussion with return demonstration of Situation Background Assessment Recommendations).

oIn-services were initiated by the Director of Nursing/Quality Improvement Nurse on 1/6/2025 to educate on notifying physicians immediately following detailed assessment with any resident change of condition to include the use of the SBAR/eInteract (Situation, Background, Assessment and Recommendations to enhance the communication information among team members). Completed on 1/30/2025.

oOn 1/6/2025 Education/In-service was initiated to the DON, ADONs by the Corporate Quality Improvement Nurse on the morning clinical start-up process to ensure that any changes of condition would be addressed. Completed 1/6/2025

[NAME] alter the process or system failure the Stop and Watch (early warning communication tool to alert a nurse or manager if they notice something different in a person's daily care routine) was initiated, training and education started to the certified nurses' aides utilizing the alert system on 1/8/25. (Verbal instruction and application along with monitoring of use to ensure understanding and compliance of the communication system) completion date 1/30/2025.

oThe SBAR/eInteract is being monitored in the clinical morning startup daily by DON/ADON/Designee.

oOversight will be provided by the Administrator/DON/Designee

oOn 1/6/25 LVN A resigned and then called in on 1/9, 1/10, 1/13 resignation was accepted immediately.

oOn 1/13/25 LVN B resigned with resignation accepted immediately

oOn 1/5/25 - LVN C was terminated.

oOn 1/17/25 - LVN A, LVN B and LVN C license was referred to the Texas Board of Nursing for further review.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 25 675988 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675988 B. Wing 02/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hilltop Park Rehabilitation and Care Center 970 Hilltop Dr Weatherford, TX 76086

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Notification protocol and SBAR understanding will be tested by giving a test to LVNs and RNs that cover SBAR education and notification of physician regarding change of condition. Oversite of the testing will be Level of Harm - Immediate managed by DON/ADON. (Initiated: 1/30/25) To ensure understanding. This test will be given to new nurses jeopardy to resident health or hired during orientation and yearly with competencies. Completion date 1/30/2025. safety oChange of condition will be reported from shift to shift up to nurse management by utilizing the Residents Affected - Some SBAR/eInteract process and 24-hour report tool and reviewed daily in clinical start-up with oversite provided by DON/ADON/Designee.

DON/ADON/Designee will be responsible for reviewing SBAR/24-hour report/nurse to nurse huddle and hand-off, daily at morning clinical start up. This will be with the oversight of the administrator. Discrepancies will be addressed immediately with root-cause analysis and brought to QAPI with the oversite with the Medical Director monthly for six months. Administrator/DON/Designee will review and ensure that understanding comprehension of the protocol.

[Facility ]

Medical Director notified of IJ (01/29/2025)

[Facility]

Monitoring of the POR Included the following:

Verification of POC. 1/31/25 at 9:30 AM with DON present.

Reviewed on 01/31/2025 at 9:39 am - Completed.

Reviewed 01/31/2025 at 9:43 am - Completed.

Reviewed 01/31/2025 at 9:50 am. Completed. On-going 3 staff left, cannot work until in-service completed.

oOn 1/06/2025 LVN A resigned and then called in on 01/9, 01/10, 01/13 resignation was accepted immediately.

oOn 01/13/2025 LVN B resigned with resignation accepted immediately

oOn 01/05/2025 - LVN C was terminated.

oOn 1/17/2025 - LVN's A, B, and C license was referred to the Texas Board of Nursing for further review.

Reviewed the employee files of Nurses A, B, and C with the documentation of the disciplinary actions taken with the DON 01/31/2025 at 9:56 am. Completed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 25 675988 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675988 B. Wing 02/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hilltop Park Rehabilitation and Care Center 970 Hilltop Dr Weatherford, TX 76086

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Reviewed the inservice sheet and the employee list provided by the facility with the D atat 1/31/25 at 9:57 am. The inservice efforts are on-going required for agency and new staff before they are allowed to work All Level of Harm - Immediate nurses employed at the facility with the exception of 2 nurses on the staff list had completed the inservices. jeopardy to resident health or They cannot work until completed. This information stating they should not clock in before they had received safety the inservice and taken the competency based test. was posted on time clock by the DON.

Residents Affected - Some Reviewed letter of notification of Immediate Jeopardy Signed by Medical Director on 01/20/2025. Reviewed signed document with DON.

Interview Verification:

,

On 01/30/2025 at In interviews from 2PM 12:30 AM with LVN G, Charge Nurse (6 AM-2 PM) LVN H (6 AM-2 PM) shift, LVN F(2 PM-10 PM) shift, LVN I (2 PM-10 PM) shift, CMA FF (6 Am -6 PM) shift, LVN K, (6 AM-2PM) shift, LVN L (2 PM -10 PM) shift LVN M PRN, LVN N Agency, CNA D (6am-6pm) shift, LVN O (2 PM - 10 PM) shift, CNA Q (2 PM-10 PM) shift, Agency CNA R. (2 PM - 10 PM) shift, LVN S (6 am - 2 pm )shift, LVN T (10pm-6am) shift, . LVN GG (10 AM-6 PM), RN U (10 PM- 6 AM) shift, CNA V (10 PM -6 AM) shift, CNA X (2 PM- 6 AM) shift, LVN Z (10 PM-6 AM), CNA AA, CNA CC (10am-6pm) shift, and LVN BB (10 AM-6 PM) shft all stated a change of condition was anything that is outside of resident's normal state. They stated Information can come from a CNA, Therapy, other staff and should be reported to the charge nurse immediately, who in turn should notify the physician. They stated the eInteract (SBAR) should be used to assess the resident for a change in condition because it was very specific to conditions. They were all able to demonstrate how to fill out the e-interact form, and a provided sample. They stated it would be passed on in shift report and documented on the communication sheet for each hall and the SBAR form would stay open

in the electronic medical record until the physician was notified. They stated nurses go in for morning report, with management to go over any change that has occurred or new orders on a physician. They stated the inservice was held on, 01/30/2025 for e-interac (SBAR) The Inservice was mandatory. A competency based test was given to each staff member over the information in the Inservice after the inservice .

Record review of In-service, Notification of Change in Condition, conducted by CCN, Admin and DON included facility definition, purpose, process for provider notification as it related to all changes or decline in condition are required to be reported to the attending physician by utilizing the facility sanctioned communication documents.

Record review of In-service titled, SBAR, conducted by Corporate Nurse, included the SBAR definition, purpose, process, relevant examples, and specific procedure as it related to all surgical wounds/incisions changes or decline in condition to be reported to the surgeon and attending physician by utilizing the facility's SBAR document. Facility Administrator and DON's signatures were included.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 25 675988 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675988 B. Wing 02/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hilltop Park Rehabilitation and Care Center 970 Hilltop Dr Weatherford, TX 76086

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 In interview with the Administrator on 01/31/2025 at 9:50 AM , he stated failure to report a change a change

in condition to the resident's nurse could be considered neglect. He stated Immediate notification to a Level of Harm - Immediate provider for any resident change in condition was important. He Knew what a change in condition was and jeopardy to resident health or was able to state signs and symptoms that would indicate a condition change such as change in LOC and safety the signs and symptoms his staff should be monitoring for infection such as fever, increased behaviors or confusion etc He further stated what and where his staff should be documenting any change in condition in Residents Affected - Some the electronic medical record (EMR) and the other parties that should be notified in addition to the provider.

He sufficiently defined abuse, neglect, and/or exploitation and the expectations of hi [TRUNCATED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 25 675988 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675988 B. Wing 02/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hilltop Park Rehabilitation and Care Center 970 Hilltop Dr Weatherford, TX 76086

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41944 potential for actual harm Based on observation, interview, and record review, the facility failed to maintain an infection and prevention Residents Affected - Few control program that included, at a minimum, a system for preventing and controlling infections for 2 of 2 residents (Resident #2 and Resident #7) reviewed for infection control (incontinent Care).

1. The facility failed to ensure CNA J washed or sanitized her hands before and during incontinent care for Resident #2.

2. The facility failed to ensure CNA D washed or sanitized her hands before and during incontinent care for Resident #7

This deficient practice placed residents at risk for cross contamination and/or acquiring an infection.

Findings include:

1. Review of Resident 2's Significant Change in Status MDS assessment dated [DATE REDACTED] revealed Resident #2 was an [AGE] year-old female originally admitted to the facility on [DATE REDACTED]. Her cognitive skills for daily decision making were severely impaired with a BIMS score of 2. Resident #2 required maximum assistance with the staff providing over one half of the support of toileting. Resident #2 was always incontinent of bladder and occasionally incontinent of bowel.

Review of Resident #2' s Face sheet included the following diagnoses: dementia with behavioral disturbance, urinary tract infection with an onset date of 01/08/2025, diarrhea with an onset date of 01/06/2025

Review of the Care Plan dated revised on 01/04/2025 for Resident #2 revealed the following focus: resident has bowel and bladder incontinence and interventions: check every 2 hours and wash and dry peri area as necessary for incontinent episodes. Report and document for signs and symptoms of UTI pain, burning, blood-tinged urine, deepening of urine color or foul-smelling urine.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 25 675988 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675988 B. Wing 02/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hilltop Park Rehabilitation and Care Center 970 Hilltop Dr Weatherford, TX 76086

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During an observation and interview on 01/07/2025 at 1:15 PM, CNA J provided incontinent care to Resident #2. CNA J entered Resident #2's room, but did not wash her hands before applying gloves. She donned a Level of Harm - Minimal harm or gown which was due to the resident requiring contact precautions. The gown was improperly donned . The potential for actual harm front of the gown hanging down off of her shoulders in the front and not tied in the back leaving her upper back and the backs of her legs exposed. She used one pair of gloves throughout the entire procedure while Residents Affected - Few cleaning the front and the back of Resident #2's perineum. She removed the urine soiled brief and placed a clean brief on the resident, wearing the same gloves that she used to clean the resident's perineal area. She then removed the gloves and saw there was no hand sanitizer in the room. She stated she just realized the resident's room did not have a sink to wash her hands. She then shrugged her shoulders and disposed of

the gloves and soiled linen in the trash and left the room. She stated she had an in-service on infection control during her orientation and was competency checked. She stated she had been employed at the facility for 2 months. When asked if she would have done anything differently during the procedure she replied I'm not worried about itand walked away.

2. Review of Resident #7's quarterly MDS dated [DATE REDACTED] revealed Resident #7 was a [AGE] year-old female originally admitted to the facility on [DATE REDACTED]. Her cognitive skills for daily decision making were moderately impaired with a BIMS score of 11. Resident #2 required maximum assistance with the staff providing over one half of the support of toileting. Resident #2 was always incontinent of bladder and bowel.

Review of Resident #7s Face sheet included the following diagnoses: Muscle wasting and atrophy, Huntington's Disease ( a progressive inherited neurologic disease that causes involuntary body movements, memory problems and damages the brain cells), and hypertension (high blood pressure).

Review of the Care Plan dated revised on 08/22/2024 for Resident #7 revealed the following focus: resident has bowel and bladder incontinence and interventions: check every 2 hours and wash and dry peri area as necessary for incontinent episodes. Report and document for signs and symptoms of UTI pain, burning, blood-tinged urine, deepening of urine color or foul-smelling urine.

During an observation on 01/07/2025 at 1:45 PM, CNA D provided incontinent care to Resident #7 using the proper technique for cleaning the perineal area. CNA D did not remove and change her gloves, and sanitize her hands before touching the clean brief after she removed, and disposed of the urine soiled brief. She washed her hand before leaving the room.

In an interview at 1:50 PM on 01/07/2025, CNA D stated she did not sanitize her hands and change her gloves before touching the clean brief that she applied to Resident #7 . She stated the failure to sanitize and change gloves could result in the spread of infection. She stated the reason she made a mistake was because she was so nervous.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 25 675988 Department of Health & Human Services Printed: 09/08/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675988 B. Wing 02/14/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Hilltop Park Rehabilitation and Care Center 970 Hilltop Dr Weatherford, TX 76086

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 3. During an interview on 01/07/2025 at 2:30 PM, the DON stated she expected staff to remove their gloves and either wash or sanitize their hands after touching a dirty area prior to moving to a clean area when Level of Harm - Minimal harm or performing incontinent care, and that all staff had been trained on this procedure. She stated she did not potential for actual harm know why CNAs J and D failed to perform hand hygiene at the appropriate time. She stated all staff had been instructed on hand washing and infection control. She stated she did competency checks on all CNAs Residents Affected - Few yearly and CNAs J and D had passed a competency check. She revealed that she would do additional in-service training with staff regarding Infection Control and Incontinent Care. She stated the failure to perform hand hygiene during resident care placed the residents at risk for infection.

During an interview on 02/07/2025 at 2:25 PM , CNA D stated she normally washed her hands after completing incontinent care and changed her gloves when moving from a dirty area to the clean area. She stated that she was just nervous and didn't remember with the surveyor watching. She stated that she had been trained and checked off on incontinent care by the

ADON.

Review of the facility's policy titled Perineal Care, revised October 2010, revealed the following elements in part: The purposes of this procedure are to provide cleanliness and comfort to the resident, to prevent infection and skin irritation, and to observe the resident's skin condition .Steps in the procedure . 2. Wash and dry your hands thoroughly. 6. Put on gloves. 9. Remove gloves and discard into designated container. 10. Wash and dry hands thoroughly. 14. Wash and dry hands thoroughly .

Review of the facility's policy titled Handwashing/Hand Hygiene dated December 22, 2023, revealed the following elements in part:

The facility considers hand hygiene the primary means to prevent the spread of infection.

Use an alcohol-based hand rub containing at least 65 % alcohol, or alternatively soap and water: before going from a contaminated body site to a clean site, after contact with a resident's intact skin, after removing gloves.e.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 25 675988