Health inspection·November 10, 2023

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. 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 MTD stated he was aware the Common Shower had missing floor tiles along the wall and next to the drain. The MTD stated the Common Shower floor tiles were in this condition when he started his employment last year in September 2022. He stated he informed the VP back in December 2022 of the condition of the floor tiles in the Common Shower. The MTD stated he was unsure of how he informed the VP, but he believes it was via a Conference Call with himself and the previous Administrator. The MTD stated he told the former ADM that the tiles were different colors, and some were missing. The MTD stated the facility had so many things that took priority over replacing the floor tiles, and fixing the floor kept getting pushed back. The MTD stated for better or worse, the State Surveyor being at the facility has pushed Administration to give him the authority to replace the tiles. The MTD stated the current ADM gave him approval to replace the missing tiles or the entire floor this morning (Friday, 11/10). The MTD stated if the residents were to walk in the area with the missing tiles, it would be an uneven foot path that could cause them to trip or fall resulting in a serious injury, or even death. Interview on 11/09/23 at 5:40 pm, CNA A stated the Common Shower had missing floor tiles close to the wall and the water drain. She stated a resident or staff member could trip and fall. CNA A stated the wheel of the shower chair could get stuck, and the resident could be injured if staff had to pull or push the chair hard to free the chair from the open space. Page 1 of 3 675518 675518 11/10/2023 The Hilltop on Main 1015 N Main Meridian, TX 76665

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview on 11/09/23 at 6:20 pm, the DON stated she started her employment in August 2023 and the floor tiles in the Common Shower room were already missing. The DON stated replacing the missing floor tiles had been discussed during the Morning Meeting. She stated the ADM discussed replacing the floor tiles on Sunday (11/12) and it would take 24 hours to cure. Interview on 11/09/23 at 7:10 pm, the ADM stated the floor tiles had been repaired in the past. She stated sometimes the floor tiles become loose due to the constant running of water. The ADM stated once they find the correct size tiles to cover the missing parts, it would be fixed immediately. Observation on 11/10/23 at 10:35 am revealed the Common Shower to still have missing floor tiles. Interview on 11/10/23 at 10:45 am, the MTD stated he will purchase the floor tiles today, but the tiles will not be the same color. He stated he had setup a website for staff to create Service Tickets, but only a few utilized it, so he disabled the website. He stated the facility reverted back to the paper method last month (October 2023). The MTD stated there was a binder at the nurse's station, and he checks the binder at the start of his shift. He stated if it were an emergency, staff would call or text him directly. Interview on 11/10/23 at 11:25 am, CNA B stated the floor tiles had been missing since she started working at the facility 4 years ago. CNA B stated it was a minor issue and she cannot understand why it was taking so long for the facility to fix it. CNA B stated for the resident, this was their home, and the shower room should reflect a home environment. CNA B stated she would not want to stand in a shower with missing and broken tiles. She stated it could cause harm to the resident, as they could cut their foot, trip and fall, or the shower chair could get stuck, and they would have to pull the resident. Interview on 11/10/23 at 11:40 am, CNA C stated the floor tiles had been in the current condition since she returned to the facility in June 2023. She stated the condition could cause the shower chair to get stuck and if they tried to pull the chair with the resident in it, the resident could fall out. CNA C stated if a resident walked on the floor, they could stump their toe, or their foot could get caught causing them to fall and hit their head on the wall. She stated she likes her home to look nice and presentable and the condition of the Common Shower's floor tiles would concern her if it was her home. Interview on 11/10/23 at 12:00 pm, CNA D stated the floors have been in this condition since she started working at the facility 6 years ago. CNA D stated being in this condition, a resident could fall or trip over the missing tile. She stated to her, the appearance of the shower room floor, was like walking into a public bathroom. Interview on 11/10/23 at 12:20 pm, CNA E stated the missing and broken tiles gradually increased over the years. CNA E stated she noticed when she was giving a resident a shower, the missing parts were much larger. CNA E stated the floor tiles being in this condition could cause the shower chair to get stuck and tip over with the resident in it. She stated it was a fall risk, and the resident could be injured. Interview on 11/10/23 at 12:40 pm, the AD stated the floor tiles in the Common Shower had been in disarray for about five years. She stated the residents in wheelchairs can slide their feet and cut or stub their toe. The AD stated the mobile residents can trip and fall and hurt themselves. She 675518 Page 2 of 3 675518 11/10/2023 The Hilltop on Main 1015 N Main Meridian, TX 76665

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some stated the residents that use a walker or wheelchair, when they were transferred to the shower chair, they can trip or fall. The AD stated even though the residents were always supervised, the staff can trip and fall on the resident. Interview on 11/10/23 at 2:30 pm, LVN B stated the missing tiles could cause the chair to tip over causing the resident to fall and cut or injure themselves. LVN B stated it could then become an infection control issue. LVN B stated a resident on a blood thinner could bleed out and a resident with diabetes can actually contract Sepsis. She stated there was a maintenance log at the nurse's station, or they can call or text the MTD if it was an emergency. Interview on 11/10/23 at 3:20 pm, the MTD informed surveyor he just returned from the store to purchase the floor tiles, but the store did not have the size required. The MTD stated he had to now order the tiles, and they will be changing out the entire floor. Interview on 11/10/23 at 3:30 pm, the ADM stated she first noticed the floor tiles missing around 6 weeks ago. She stated she did not report the missing tiles to Corporate because they had so many other things that they had already reported. She stated she told the MTD to start looking for tiles, but he could not find the right size. The ADM stated they were going to replace the entire floor. She stated they will use the Common Shower on the Secure Unit if it takes more than one day. Record review of the Facility's undated Physical Environment - Maintenance Service Policy revealed, Maintenance service shall be provided to all areas of the building, grounds, and equipment. Under the Policy Interpretation and Implementation section, it reads: 1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 2. Functions of maintenance personnel include, but are not limited to: b. Maintaining the building in good repair and free from hazards. i. Providing routinely scheduled maintenance service to all areas. 3. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner. Record review of the Facility's undated Physical Environment - Work Orders, Maintenance Policy revealed, Maintenance work orders shall be completed in order to establish a priority of maintenance service. 2. It shall be the responsibility of the department directors to fill out and forward such work orders to the Maintenance Director. 675518 Page 3 of 3