HILLTOP RESERVE

An administrative relicensure survey was completed on 6/30/26. No deficiencies were cited.

A revisit survey was completed on 8/21/25 for all previous deficiencies cited on 5/7/25. 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 with complaint #CO39570 was completed on 5/7/25. A deficiency was cited.

Based on observation and interview, the residence failed to ensure that qualified medication administration persons (QMAPs) were trained in and applied nationally recognized protocols for basic infection control and prevention when preparing and administering medications affecting three residents (#1-#3), whose medications were administered. Findings include:On 5/6/25 from approximately 7:30 a.m. to 8:30 a.m., the following was observed during medication administration:Staff #1 prepared medications for Resident #1. Staff #1 did not perform any hand hygiene. Staff #1 touched their keys, the medication cart, medication containers, the computer keyboard and screen, and the door handle of Resident #1's room. During medication administration, Staff #1 hand-fed the medications with a spoon to Resident #1 and did not perform hand hygiene before or after administering the medications. Staff #1 prepared medications for Resident #2. Staff #1 did not perform any hand hygiene. Staff #1 touched their keys, the medication cart, medication containers, the computer keyboard and screen, crushed Resident #2's medications and poured them into a cup with applesauce, then mixed with a spoon, and touched the door handle of Resident #2's room. During medication administration, Staff #1 assisted Resident #2 with sitting up in bed, grabbed their walker to assist with sitting up, and hand-fed the crushed medications with a spoon to Resident #2. Staff #1 did not perform hand hygiene before or after administering the medication. Staff #1 prepared medications for Resident #3. Staff #1 did not perform any hand hygiene. Staff #1 touched their keys, the medication cart, medication containers, the computer keyboard and screen, and the door handle of Resident #3's room. During medication administration, Staff #1 assisted Resident #3 with sitting up in bed, grabbed their walker to assist with sitting up, left the room with the medication to get assistance from other staff with Resident #3's care, grabbed gloves from the medication cart, returned to Resident #3's room to assist with cares then hand-fed the medication with a spoon to Resident #3 with gloves on. Staff #1 did not perform hand hygiene before or after administering the medication. Similar deficient practice occurred with Staff #2 during medication administration. On 5/6/25 at 8:16 a.m., Staff #1 reported they had been trained to apply protocols for basic infection control and prevention when preparing and administering medications. She reported not having enough time to wash her hands or sanitize them after each medication administration, and that she should have washed them. On 5/7/25, at 11:49 a.m., the health services director reported that QMAPs were expected to wash their hands after each resident's medication administration.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY. No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.12.1 The assisted living residence shall make available, either directly or indirectly through a resident agreement, the following services, sufficient to meet the needs of the residents: (A) A physically safe and sanitary environment including, but not limited to, measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population;13.12 (C) All documentation of the investigation, outcomes, and steps taken shall be retained by the assisted living residence, including, but not limited to, details of any interviews and/or records used in the investigation. Such documentation shall be made available for review at the Department's request. (1) Documentation on the investigation, outcomes, and steps taken may be maintained separately from the resident record, in which case a summary of the investigation and steps taken shall be included in the resident's care plan and progress notes. 14.20 The assisted living residence shall contact the authorized practitioner for clarification of any orders which are incomplete or unclear and obtain new orders in writing. 14.21 The assisted living residence shall be responsible for complying with authorized practitioner orders associated with medication administration, except for those medications which a resident self-administers. 14.29 All prescribed and PRN medications shall be listed and recorded on a medication administration record (MAR) which contains the name and date of birth of the resident, the resident's room location, any known allergies, and the name and telephone number of the resident's authorized practitioner. (A) The medication administration record shall reflect the name, strength, dosage, and mode of administration of each medication, the date the order was received, the date and time of administration, any special considerations related to administration, and the signature or initial of the person administering the medication. 14.38 All medications shall be stored in a locked cabinet, cart, or storage area when unattended by qualified medication administration persons or other licensed staff. 25.10 In addition to the information required for a resident care plan at Part 12.10, the care plan for each resident in a secure environment shall include the following: (A) A description of the resident's wandering patterns and known behavioral expressions, along with individualized approaches to be implemented by staff to protect the resident and other residents with whom they have contact; (B) A description of how the resident will have continuous independent access to his or her individual room, along with the ALR's plan to protect the resident from unwanted visitation by other residents; (C) Identification of the type and level of staff oversight, monitoring, and/or accompaniment that the ALR deems necessary to meet the needs of the resident within the secure environment and secure outdoor area; and (D) Documentation describing the personal grooming and hygiene items that are determined safe for the resident to have in their own possession for self-care, and how those items are stored to prevent unauthorized access by other residents.

A revisit survey was completed on 10/8/24 for all previous deficiencies cited on 7/31/24. 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 licensure complaint, prompted by #CO30677, #CO31295, #CO33554, and #CO34616, was completed on 7/31/24. A deficiency was cited.

Based on observation, record review and interview, the residence failed to ensure one sample staff member (#3) was trained on mechanical lifts affecting two residents with mechanical lifts (#5,#7). Findings Include:1. Record Reviewa. Resident #5 was admitted to the residence on 6/15/22 with diagnoses including: difficulty in walking, not elsewhere classified, muscle weakness (generalized), and other lack of coordination. A care plan for Resident #5, dated 6/19/24, read in part the resident required transfer assistance with a mechanical lift.b. Resident #9 was admitted to the residence on 5/1/24 with diagnoses including: multiple sclerosis, polyneuropathy, and primary generalized osteoarthritis. A care plan for Resident #9, dated 7/23/24, read in part the resident required transfer assistance with a mechanical lift. Personnel files for Staff #3 revealed no evidence of training on mechanical lifts. A review of the staff schedule revealed Staff #3 worked the morning shifts of 7/24, 7/25, and 7/26 without training on mechanical lifts. 2. InterviewOn 7/31/24 at 5:30 p.m. the administrator stated they had an inservice training on lifts from May 2024, and asked if she could provide this now. The administrator stated she was aware staff working with residents with mechanical lifts were required to be trained.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.14.29 All prescribed and PRN medications shall be listed and recorded on a medication administration record (MAR) which contains the name and date of birth of the resident, the resident ' s room location, any known allergies, and the name and telephone number of the resident ' s authorized practitioner. (A) The medication administration record shall reflect the name, strength, dosage, and mode of administration of each medication, the date the order was received, the date and time of administration, any special considerations related to administration, and the signature or initial of the person administering the medication. (B) As part of the medication administration record, the assisted living residence shall maintain a legible list of the names of the persons utilizing the record for medication administration, along with each of their signatures and, if used, their initials. (C) Each qualified medication administration person, nurse, or practitioner shall accurately document each medication administration or monitoring event at the time the event iscompleted for each resident. (D) Each qualified medication administration person, nurse, or authorized practitioner shall document accurate information in the medication administration record including any medication omissions, refusals, and resident reported responses to medications.

A licensure complaint, prompted by #CO30097, was completed on 1/17/23. No deficiencies were cited.