The Hilltop on Main

Inspectors wroteBased on interview and record review, the facility failed to have licensed nurses on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans, in thatThe facility failed to have a 24 hour licensed nursing service on 7/19/25, 7/20/25, 08/02/25 and 09/27/25This failure placed all residents at risk for unmet needs and/or injury.

Inspectors wroteBased on interview, and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week and designate a registered nurse to serve as the director of nursing on a full-time basis for 1 of 1 DON (DON) and 1 of 1 RN (RN) reviewed for DON and RN coverage. The facility failed to have an RN on a regular basis in the facility since August 2025. The facility failed to have a full-time DON on regular basis from 10/01/25 to 02/28/26. This failure could place residents at risk of harm due to being left without supervisory coverage for coordination of events such as emergency care, disasters and providing quality care.

Inspectors wroteBased on observations, interviews and record review, the facility failed to assess the resident for risk of entrapment from bed rails prior to installation and review the risk and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 5 (Resident #2, #7, #12, #18, #26) of 14 residents reviewed for bedrails. The facility failed to properly assess the risk of entrapment, or obtain documentation of informed consents for Resident #2, #7, #12, #18, and #26 prior to the installation and use of bed rails. This failure could place residents at risk of entrapment, restraint, and injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post daily information that included the facility name, current date, total number and actual hours worked by registered nurses, licensed practical or licensed vocational nurses, certified nurse aides directly responsible for resident care per shift and the resident census for 3 days (03/01/26, 03/02/26 and 03/03/26) of 3 days reviewed for posted nurse staffing information. The facility did not post the required current nurse staffing information from 03/01/26 through 03/03/26. This failure could place residents at risk of not having access to information regarding staffing data and the facility census.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the resident assessment accurately reflected the resident's status for 1 of 13 residents (Resident #8) reviewed for accuracy of assessments. The facility failed to accurately indicate Resident #8's receipt of injections and insulin injections on the resident's quarterly MDS assessment completed on 12/10/2025. This failure could place residents at risk of incorrect care and services necessary for their physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs safely and in a manner that promoted each resident's rights, physical, mental, and psychosocial well-being for 2 of 2 (Resident #22 and #24) reviewed for competent nursing staff. The facility failed to ensure CNA A utilized appropriate communication, intervention, and redirection methods with Resident #24 which led to an escalation of conflict between Resident #22 and Resident #24 resulting in Resident #22 making threatening gestures and a threat of harm to Resident #24. This failure could place the residents at risk of serious injury or harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for the facility's only kitchen reviewed for food service safety. 1. The facility failed to ensure food was labeled with a product name and use by date in the facility's only walk-in freezer, walk-in cooler, and side-by-side refrigerator. 2. The facility failed to clean, and sanitize, the kitchen's only industrial can opener. 3. The facility failed to ensure the sanitizer in the facility's only dishwasher was at 50 PPM. These failures placed residents at the facility at risk for ingesting food borne pathogens.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 1 (Resident #1) of 6 residents reviewed for infection control. The DON failed to use enhanced barrier precautions during a gastrostomy feeding for Resident #1 on 01/22/2025 by not donning a gown prior to administering the feeding. This failure could place residents at risk of cross contamination which could result in infections or illness.

Inspectors wroteBased on interview, and record review, the facility failed to implement a comprehensive care plan that describes the services to be furnished to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 4 residents(Resident #1) reviewed for care plans. The facility failed to revise the nutritional careplan and develop and implement a care plan for severe weight loss of 16.1% and refusal to eat identified in a two month period from admission on [DATE] and last record of weight on 02/05/2024. The facility failed to develop and implement a care plan related to Resident # 1 self isolating, blocking his room door,signs, symptoms of depression, and refusal to see Psych NP on 01/15/2024 which resulted in Resident # 1 to attempt suicide on 03/01/2024. An Immediate Jeopardy (IJ) situation was identified on 03/22/2024 at 3:00 p.m. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that was not possible or the resident preferences indicated otherwise for 1 of 4 residents (Resident #1) reviewed for nutrition status maintenance. The facility failed to ensure Resident # 1 did not sustain a severe weight loss of 16.1% in a two month period from admission on [DATE] and last record of weight on 02/05/2024 The facility failed to follow MD order to take monthly weights beginning on 01/01/2024 for a weight to be taken the 1st through the 5th of each month. The facility failed to include 01/16/2024 weight of 134.6 in Resident # 1's weight log. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to ensure a resident who displays or is diagnosed with a mental disorder or psychosocial adjustment disorder receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for 1 of 4 residents (Resident # 1) reviewed for treatment and services for mental and psychosocial concerns. The facility failed to develop and implement a plan of care to address Resident #1's signs and symptoms first documented on 01/15/2024 when Resident #1 refused to see the Psych NP for signs and symptoms of depression. CMA D failed to to report Resident #1 expressing to her many times that he was tired, his body was giving out, and he was ready to go. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 (Resident #1) of 4 residents reviewed for psychotropic drug use. The facility failed to: 1. ensure Resident #1 was prescribed Seroquel for a specific diagnosis and instead prescribed it for behavioral disturbance at bedtime This failure could affect residents by placing them at risk of receiving psychotropic medications which could cause a decrease in quality of life and increase the risk of injury.

Inspectors wroteBased on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 9 of 30 days reviewed for RN coverage. The facility failed to ensure they had an RN on duty on 11/5/23,11/11/23,11/12/23,11/18/23,11/19/23,11/25/23, 11/26/23,12/3/23 and 12/04/23. This failure placed residents at risk of missed nursing assessments, interventions, care, and treatments. Findings Include Review of RN staffing for November 2023 revealed zero hours worked by an RN on 11/5/23,11/11/23,11/12/23,11/18/23,11/19/23,11/25/23,11/26/23. Review of RN staffing for December 2023 revealed zero hours worked by an RN on 12/3/23 and 12/04/23. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 4 of 5 residents reviewed for medication administration (Resident's #31, #10, #14, and #8) and for 5 of 6 resident (Resident's #31, #10, #30, #14, and #8) reviewed for blood pressure readings. MA failed to properly sanitize blood pressure cuff when moving from one resident to another resident when administering medications and obtaining blood pressure for Residents #31, #10, #14, and #8 . MA failed to wash or sanitize her hands while going from one resident to another resident when administering medication for Resident's #31, #10, #30, #14, and #8. This deficient practice placed residents at risk for cross contamination and the spread of infection.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide a safe, functional, sanitary and comfortable environment for 1 (Common Shower) of 1 shower room observed for Environment. The floor tiles had been missing from the floor as far back as 6 years. The facility failed to have an effective maintenance communication system for when items needed to be repaired or replaced, which resulted in an unsafe environment in the Residents' Common Shower room. This failure could place residents at risk of tripping and falling, the shower chair wheels getting stuck, or cross contamination, which could cause injury, pain, distress and gastro-intestinal illnesses and result in a decrease in their health and psycho-social well-being.