The Hilltop On Main

Based 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.Findings included: Record review of the PBJ staffing data report for the fourth quarter of the financial year 2025 reflected that there was no licensed nursing coverage for 24 hours/day on 07/09/25, 07/20/25, 08/02/25 and 09/27/25.During an interview on 03/03/26 at 10:42 a.m., LVN B reported that she had worked at the facility approximately 2.5 years prior to the interview date. She stated that her work hours were from 6:00 AM to 2:00 PM, Monday through Friday. LVN B indicated that she did not recall any days during her tenure when the facility lacked licensed nurses. She emphasized the importance of 24/7 licensed nurse coverage in ensuring resident safety, noting that such staffing supports staff in effectively…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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.Findings included:Record review of the facility timecard report revealed the facility did not have a DON from 10/01/25 to 11/30/25 and 12/26/25 to 02/28/26.Record review of the facility time card report revealed the facility did not have RN coverage in year 2025 on 09/01, 09/02, 09/05 to 09/07 , 09/10 to 09/13, 09/15 to 10/05, 10/07 to 10/10, 10/13 to 10/23, 10/25 to 11/14, 11/17 to 11/21 , 11/24 to 12/3 , 12/5, 12/9…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: Record review on 3/3/2026 of Resident #2's admission record and 5-day scheduled MDS assessment, dated 1/23/2026, reflected an [AGE] year-old female admitted [DATE] and readmitted on [DATE]. Resident #2 was shown to be her own decision maker with no other RP listed. The resident's diagnoses included cerebral infarction (stroke), contracture of right hand…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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.Findings included:During an observation on 03/01/26 at 10:00 a.m., it was revealed that there was no staffing posting present at the facility with facility name and date containing the total number of staff and actual hours worked by RNs, LPNs and LVNs or CNAs who are directly responsible for resident care.During an observation and interview on 03/03/26 at 1:25 p.m., LVN C searched the nursing station and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: Record review on 3/2/2026 of Resident #8's quarterly MDS assessment, dated 12/19/2025, reflected a [AGE] year-old male admitted [DATE]. His diagnoses included neurocognitive disorder with Lewy bodies (protein deposits that develop in nerve cells of the brain that affect thinking, memory and movement), Type 2 Diabetes with moderate non-proliferative retinopathy without macular edema, right eye (a condition characterized by insulin resistance and high blood sugar that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: Record review on 3/1/2026 of Resident #22's admission record and modified quarterly MDS assessment, dated 2/13/2026, reflected an [AGE] year-old male admitted on /2022 and readmitted [DATE]. Resident #22 was his own RP. Resident #22's diagnoses included chronic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings included: Observation and interview on 1/21/2025 at 10:08 AM revealed the kitchen's only industrial can opener (a metal can opener attached to a table/counter to open large metal cans.) The industrial can opener had a 6-inch-long handle which rotated a metal gear (like the size and shape of a hockey puck,) which in turn rotated a metal can. On the underside of the 6-inch-long handle mechanism, was a 1-inch…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: Record review of Resident #1 face sheet dated 1/22/2025 reflected she was a [AGE] year-old female with diagnoses of unspecified dementia (a loss of thinking, remembering, and reasoning skills), type 2 diabetes mellitus (elevated blood sugars), dysphagia (difficulty swallowing), and encounter for attention to gastrostomy (care of gastrostomy tube). Record review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: Review of Resident #1's undated face sheet revealed an [AGE] year-old male with an admission date of 12/05/2023. Diagnoses included hypertension (high blood pressure), cardiomyopathy (disease of heart muscle), hyperlipidemia (high cholesterol), and protein-calorie malnutrition (inadequate amount of protein). Review of Resident #1's MDS…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Interview on 12/7/23 at 1145 AM with DON, she stated that she is aware of the lack of RN coverage every other weekend, they are advertising for an RN, but because of the small community and the commute time from the larger city in the area, they have very little response. She stated that she is aware of both the regulation and their policy that requires RN coverage 8 hours a day 7 days a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings included: Record Review of Resident #31's face sheet dated 12/06/23 reflected Resident #31 was a [AGE] year-old male with an admission date of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings included: Observation on 11/09/23 at 3:30 pm revealed the floor in the Common Shower room with multiple sections of missing floor tiles. There were missing sections of floor tile along the wall, beside the drain, and between the wall and the drain. The floor tiles were not a consistent color. Interview on 11/09/23 at 4:55 pm, the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.