Commons of Hilltop, the

A revisit survey was completed on 1/21/26 for all previous deficiencies cited on 9/23/25. The facility is in compliance with all deficiencies that were cited. Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

A relicensure survey was completed on 9/23/25. Deficiencies were cited. Based on observations and interviews, the residence failed to ensure that qualified medication administration persons (QMAP) applied nationally recognized protocols for basic infection control and prevention when preparing and administering medication, affecting four of four residents observed during medication administration (#13, #14, #15, #16).Findings Include:1. ObservationsDuring medication administration on 9/23/25 from 8:42 a.m. to 9:18 a.m., Staff #5 failed to perform proper hand hygiene between residents. Staff #5 donned gloves, then administered medications and eye drops to Resident #13. After completing the task, Staff #5 doffed their gloves. Without performing hand hygi.. Based on records review and interviews, the residence failed to complete a pre-admission assessment to determine appropriateness and need for secure environment residency that included all required elements, affecting two of two sampled residents who resided in the secure environment (#6, #7).Findings include:1. Record ReviewResident #6 was admitted to the residence on 9/18/23 with a diagnosis of dementia.Resident #7 was admitted to the residence on 9/1/21 with a diagnosis of dementia.On 9/23/25 at 2:24 p.m., a request for the pre-admission practitioner assessment was requested. A practitioner assessment was found for Resident #6, but not for Resident #7. The assessment provid.. Based on records review and interviews, the residence failed to ensure that the resident' s authorized practitioner was promptly notified of the resident' s pattern of refusal of prescribed medications, affecting two of two sample residents who resided in the secure environment (#6, #7).Findings include:1. Record ReviewResident #7 was admitted to the residence on 9/1/21 with a diagnosis of dementia.A practitioner' s order dated 4/24/25, read that the residence was to administer acetaminophen 500mg three times daily. A medication administration record (MAR), dated 8/6/25, 8/10/25, 8/14/25, 8/18/25, and 9/21/25 read that Resident #7 refused the acetaminophen despite being asked seve.. Based on records review and interviews, the residence failed to include all required elements of the resident' s care plan who resided in the secure environment, affecting two of two sampled residents who resided in the secure environment (#6, #7).Findings Include:1. Record ReviewResident #6 was admitted to the residence on 9/18/23 with a diagnosis of dementia.Resident #7 was admitted to the residence on 9/1/21 with a diagnosis of dementia.On 9/23/25 at 2:31 p.m., a request for the enhanced care plans were requested for Residents #6 and #7.A care plan with an effective date of 9/18/25 to present read in part:that Resident #6 needed a two-person assist with bathing ..... THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY. No response is necessary. The residence was advised that it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.7.22 Only appropriately skilled professionals may train personal care workers and their supervisors on specialized techniques beyond general personal care and assistance with activities of daily living as defined in these rules. (Examples include, but are not limited to, transfers requiring specialized equipment and assistance with therapeutic diets). Personal care workers and their supervisors shall be evaluated for ..

A recertification survey was completed on 9/23/25. Deficiencies were cited. Based on records review and interviews, the facility (residence) failed to conduct an assessment before admission that documented that the setting would support the member (resident) and their needs, as well as develop the resident' s care plan with appropriate supports identified to enable as independent a life as possible, affecting two of eight residents who reside in the secure environment (#6, #7).Findings Include:1. Record ReviewResident #6 was admitted to the residence on 9/18/23 with a diagnosis of dementia.Resident #7 was admitted to the residence on 9/1/21 with a diagnosis of dementia.On 9/23/25 at 2:24 p.m., a request for the pre-admission practitioner assessment was requested. A practitioner assessment was found for Resident #6, but not for Resident #7. The assessment provided for Resident #6, dated 7/8/24, failed to include her cognitive deficits that contribute to wandering, compromised safety awareness, and any other types of conduct. The assessment also failed to include detailed information from Resident #6' s family concerning the resident' s recent relevant history and patterns of reduced safety awareness and wandering, along with any strategies used to prevent unsafe wandering or successful exiting, and other known types of conduct. 2. InterviewsOn 9/23/25 at 4:46 p.m., the administrator stated she was aware of the required elements for the pre-a.. Based on records review and interviews, the facility (residence) failed to ensure that a member' s (resident' s) refusal to take medications was reported to the resident' s licensed medical provider (authorized practitioner), affecting two of eight residents who reside in the secure environment (#6, #7). Findings include:1. Record ReviewResident #7 was admitted to the residence on 9/1/21 with a diagnosis of dementia.A practitioner' s order dated 4/24/25, read that the residence was to administer acetaminophen 500mg three times daily. A medication administration record (MAR), dated 8/6/25, 8/10/25, 8/14/25, 8/18/25, and 9/21/25 read that Resident #7 refused the acetaminophen despite being asked several times. A request for refusal notification forms to the practitioner were requested on 9/23/25, however the residence did not have any. 2. Similar deficient practice was found for resident #6. 3. InterviewsOn 9/23/25 at 5:11 p.m., the administrator stated the residence did not reach out to the practitioner when Resident #6 and #7 were refusing their medication and stated she would expect her staff to reach out to the practitioner each time a resident refused their prescribed medication.