The Hilltop on Main

In the surveyor’s words

From the most serious findings on record at The Hilltop on Main, in the surveyor’s own words.

• Immediate jeopardy, isolatedF656Mar 26, 2024

  Based 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 12/05/2023 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. […]

• Immediate jeopardy, isolatedF692Mar 26, 2024

  Based 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 12/05/2023 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. […]

• Immediate jeopardy, isolatedF742Mar 26, 2024

  Based 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. […]

• No harm, potential for more than minimal, widespreadF725Mar 3, 2026

  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. […]

• No harm, potential for more than minimal, widespreadF727Mar 3, 2026

  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… […]