Health inspection·December 7, 2023

F 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. 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. Residents Affected - Many 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 week. They have reached out to corporate for assistance and are currently not utilizing outside agencies that provide contract nursing staff. She stated that she is available by phone and lives 20 minutes away, so she does not see any potential for harm as she is available if needed. She also stated Page 1 of 7 675518 675518 12/07/2023 The Hilltop on Main 1015 N Main Meridian, TX 76665

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many there are clear protocols for any resident injuries or illnesses that may happen when an RN is not in the building, that include always contacting the resident's physician. Interview on 12/7/2023 at 2:00 pm with ADM, stated that she is aware of the holes in the RN coverage and is aware of the regulation that requires 8 hours of RN coverage each day, 7 days a week. She stated that their policy also states they are to have an RN 8 hours a day , 7 days a week. They have open positions and are actively recruiting but face barriers of having to compete with other small-town facilities and the commute from a bigger city. She stated that the DON is available by phone, and she feels that there is no potential for harm to the residents because of the lack of coverage in the building. Record Review of Policy titled Department Supervision, Nursing dated August 2022, revealed 2. A registered nurse provide services at least eight (8) consecutive hours every 24 hours, seven (7) days a week. 675518 Page 2 of 7 675518 12/07/2023 The Hilltop on Main 1015 N Main Meridian, TX 76665

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **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. Residents Affected - Some 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 12/21/22. Resident #31's diagnoses included peripheral vascular disease (a sign of fatty deposits and calcium building up in the walls of the arteries), hypertension (high blood pressure - long term condition in which blood pressure in arteries is persistently elevated), anxiety (an emotion which is characterized by an unpleasant state of inner turmoil and includes feelings of dread over anticipated events), and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). Record Review of the most recent quarterly MDS assessment dated [DATE] reflected Resident #31 had a BIMS score of 12 indicating Resident #31 was moderately cognitively impaired. MDS reflected resident required supervision of 1 person with bed mobility, transfer, dressing, eating, and toileting, and limited assist of one person for personal hygiene. An interview and observation on 12/05/23 at 8:57 AM revealed Resident #31 was lying in bed on top of covers fully dressed. Resident appeared clean and stated he was doing well, and staff took good care of him. He stated he had no concerns. Record Review of Resident #10's face sheet dated 12/06/23 reflected Resident #10 was an [AGE] year-old male with an admission date of 03/08/22. Resident #10's diagnoses included dementia (decline in cognitive abilities that impact a person's ability to perform everyday activities), hypertension (high blood pressure long term condition in which blood pressure in arteries is persistently elevated), anxiety (an emotion which is characterized by an unpleasant state of inner turmoil and includes feelings of dread over anticipated events), and major depressive disorder (mood disorder that causes a persistent feeling of sadness and loss of interest). Record Review of the most recent quarterly MDS assessment dated [DATE] reflected Resident #10 had a BIMS score of 11 indicating Resident #10 was moderately cognitively impaired. MDS reflected resident required supervision of 1 person with bed mobility, transfer, eating, and toileting, and limited assist of one person for dressing and personal hygiene. 675518 Page 3 of 7 675518 12/07/2023 The Hilltop on Main 1015 N Main Meridian, TX 76665

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some An interview and observation on 12/05/23 at 9:20 AM revealed Resident #10 was lying in bed with blankets pulled up to chest area. Resident #10 appeared clean and stated he was doing fine, and staff took good care of him. He stated he had no concerns with his medications or anything else at that time. Record Review of Resident #30's face sheet dated 12/06/23 reflected Resident #30 was a [AGE] year-old male with an admission date of 11/14/22. Resident #30's diagnoses included peripheral vascular disease (a sign of fatty deposits and calcium building up in the walls of the arteries), hypertension (high blood pressure - long term condition in which blood pressure in arteries is persistently elevated), COPD (progressive lung disease characterized by long-term respiratory symptoms and airflow limitation), and anemia (condition in which the blood doesn't have enough healthy red blood cells). Record Review of the most recent annual MDS assessment dated [DATE] reflected Resident #30 had a BIMS score of 12 indicating Resident #30 was moderately cognitively impaired. MDS reflected resident required supervision of 1 person with bed mobility, transfer, dressing, eating, and toileting, and limited assist of one person for personal hygiene. In an observation and interview on 12/05/23 at 9:27 AM Resident #30 was observed sitting up on the side of his bed with blankets draped over his lap. Resident #30 appeared clean and groomed and was in no sign of distress. Resident #30 stated everything was fine and he was happy in the facility. He stated he was ready to go to smoke break at that time and he had no concerns. Record Review of Resident #14's face sheet dated 12/06/23 reflected Resident #14 was an [AGE] year-old male with an admission date of 06/05/23. Resident #14's diagnoses included dementia (decline in cognitive abilities that impact a person's ability to perform everyday activities), hypertension (high blood pressure long term condition in which blood pressure in arteries is persistently elevated), cerebral infarction (stroke), and hyperlipidemia (abnormally high levels of any or all lipids or lipoproteins in the blood). Record Review of the most recent quarterly MDS assessment dated [DATE] reflected Resident #14 had a BIMS score of 06 indicating Resident #14 was severely cognitively impaired. MDS reflected resident required supervision of 1 person with bed mobility, transfer, supervision only for eating, limited assist of one person for dressing, and extensive assist of one person for toileting and personal hygiene. In an observation and interview on 12/05/23 at 9:39 AM Resident #14 was observed lying in bed with covers over his head. He stated he did not want to talk to anyone, and he wanted his door shut immediately. Record Review of Resident #8's face sheet dated 12/06/23 reflected Resident #8 was an [AGE] year-old male with an admission date of 01/25/23. Resident #8's diagnoses included anxiety (an emotion which is characterized by an unpleasant state of inner turmoil and includes feelings of dread over anticipated events), hypertension (high blood pressure - long term condition in which blood pressure in arteries is persistently elevated), COPD (progressive lung disease characterized by long-term respiratory symptoms and airflow limitation), and Alzheimer's Disease (a progressive disease that destroys memory and other important mental functions). Record Review of the most recent quarterly MDS assessment dated [DATE] reflected Resident #8 had a BIMS score of 08 indicating Resident #8 was moderately cognitively impaired. MDS reflected resident 675518 Page 4 of 7 675518 12/07/2023 The Hilltop on Main 1015 N Main Meridian, TX 76665

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some required supervision with set-up help for eating, limited assist of one staff for with bed mobility, transfer, dressing, and personal hygiene, and limited assist of two persons for toilet use. In an observation and interview on 12/05/23 at 9:45 AM Resident #8 was observed sitting up in his wheelchair. Resident #8 was clean and dressed appropriately. Resident #8 stated he was doing great, and he was well taken care of by the staff. He stated he had no concerns with his medications and everything else was great as well. In an observation on 12/05/23 at 8:47 AM the MA took a blood pressure reading with an automated cuff on Resident #31 without washing her hands after she had given medication to another resident. In an observation on 12/05/23 at 8:55 AM the MA administered medication to Resident #31 without washing her hands after she had given medication to another resident. In an observation on 12/05/23 at 9:07 AM the MA took a blood pressure reading with an automated cuff on Resident #10 without sanitizing the blood pressure cuff which had just previously been used on Resident #31 and without washing hands after she had given medication to Resident #31. In an observation on 12/05/23 at 9:14 AM the MA administered medication to Resident #10 without washing her hands after she had given medication to Resident #31. In an observation on 12/05/23 at 9:24 AM of Resident #31 and Resident #10's room, a sink and soap was available for handwashing right inside the door and was visible to those who may have entered or exited the room. In an observation on 12/05/23 at 9:25 AM of hallway of medication administration pass outside of Resident #31, #10, #30, #14, and #8 's room, there were 5 hand sanitizer dispensers hanging on the wall full of hand sanitizer. In an observation on 12/05/23 at 9:26 AM the MA took a blood pressure reading with an automated cuff on Resident #30 without sanitizing the blood pressure cuff which had just previously been used on Resident #10 and washing her hands after she had given medication to Resident #10. In an observation on 12/05/23 at 9:29 AM of hallway of medication cart which the MA had used to pass medications to Resident's #31, #10, #30, #14, and #8, a bottle of hand sanitizer was available on side of medication cart and a hand sanitizer dispenser was attached to the side of the medication cart. Both the bottle and dispenser had hand sanitizer inside. In an observation on 12/05/23 at 9:32 AM the MA took a blood pressure reading with an automated cuff on Resident #14 without sanitizing the blood pressure cuff which had just previously used on Resident #30 without washing her hands. In an observation on 12/05/23 at 9:36 AM the MA administered medication to Resident #14 without washing her hands after she had taken a blood pressure reading for Resident #30. In an observation on 12/05/23 at 9:43 AM the MA took a blood pressure reading with an automated cuff on Resident #8 without sanitizing the blood pressure cuff which had just previously been used on Resident #14 without washing her hands after she had given medication to Resident #14. 675518 Page 5 of 7 675518 12/07/2023 The Hilltop on Main 1015 N Main Meridian, TX 76665

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some In an observation on 12/05/23 at 9:43 AM the MA administered medication to Resident #8 without washing her hands after she had given medication to Resident #14. In an observation on 12/05/23 at 9:46 AM of Resident #30, Resident #14, and Resident #8's room, a sink and soap was available for handwashing right inside the door and was visible to those entering or exiting residents rooms. In an interview on 12/05/23 at 9:55 AM the MA stated she had not sanitized or washed her hands during the medication pass and she had not sanitized the blood pressure cuff in between obtaining blood pressures on Residents #31, #10, #30, #14, and #8. She stated she should have washed her hands in between every resident's medication pass and she should have sanitized the blood pressure cuff in between use for each resident as well. She stated she had been trained on handwashing and sanitizing equipment, medication administration, and infection control. She stated it was the facility policy to wash or sanitize her hands in between each resident and also to sanitize the blood pressure cuff or any equipment between residents. She stated if hands were not washed or sanitized in between residents' medication administration or blood pressure cuffs were not sanitized after use in between residents, that could cause the spread of infection and put residents at risk for infection. In an interview on 12/06/23 at 2:13 PM the ADM stated staff should have sanitized equipment, including blood pressure cuff's, with use in between residents and staff should have washed their hands at all times when going from one resident to the next during medication pass or any other time. She stated it was facility policy to do both. She stated staff had been trained on handwashing and sanitizing their hands and also on sanitizing equipment, including blood pressure cuff's, infection control, and medication administration. She stated if staff did not wash or sanitize their hands or did not sanitize a blood pressure cuff when using for multiple residents in between residents, it could cause the transfer or spread of infection from resident to resident. In an interview on 12/07/23 at 10:33 AM the DON stated staff should have washed or sanitized their hands in between residents while administering medications and they should have sanitized any equipment, including blood pressure cuffs, when going from one resident to another. She stated it was the facility policy for staff to wash or sanitize hands and to sanitize any equipment used when they went from one resident to the next. She stated staff had been trained on infection control, handwashing, sanitizing equipment, and medication administration. She stated they all knew what could happen if staff had not washed or sanitized their hands or sanitized equipment, such as blood pressure cuffs, when they went from one resident to another, and residents could have gotten sick due to the spread of infection. Record review of the Handwashing/Hand Hygiene policy dated 2001 and revised August 2015, reflected the following: Policy Statement: The facility considers hand hygiene the primary means to prevent the spread of infection. Policy Interpretation and Implementation: 2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. 6. Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: b. Before and after direct contact with residents; c. Before preparing or handling medications; i. After contact with a resident's intact skin; l. After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident . Record review of the Cleaning and Disinfection of Resident-Care Items and Equipment) policy dated 2001 and revised September 2022 reflected the following: Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC 675518 Page 6 of 7 675518 12/07/2023 The Hilltop on Main 1015 N Main Meridian, TX 76665

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some recommendations for disinfection and the OSHA Bloodborne Pathogens Standard. 1. The [NAME] Classification System is used to distinguish the levels of sterilization/disinfection necessary for items used in resident care: c. non-critical items are those that came in contact with intact skin but not mucous membranes. (1) Non-critical resident-care items include bedpans, blood pressure cuffs, crutches, and computers. (3) Non-critical items require cleaning followed by either low- or intermediate- level disinfection following manufacturers' instructions. Disinfection is performed with an EPA-registered disinfectant labeled for use in healthcare settings. All applicable label instructions on EPA-registered disinfectant products are followed (e.g., use-dilution, shelf life, storage, material compatibility, safe use and disposal). 5. Reusable items are cleaned and disinfected or sterilized between residents. 7. Only equipment that is designated reusable is used by more than one resident. Record review of the Infection Control Guidelines for All Nursing Procedures policy dated 2001 and revised August 2012 reflected the following: Purpose: To provide guidelines for general infection control while caring for residents. General Guidelines: 1. Standard Precautions will be used in the care of all residents in all situations regardless of suspected or confirmed infectious diseases. Standard Precautions apply to blood, body fluids, secretions, and excretions regardless of whether or not they contain visible blood, non-intact skin, and/or mucous membranes. 3. Employees must wash their hands for (10) to (15) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: a. before and after direct contact with residents. Record review of the Standard Precautions) policy dated 2001 and revised September 2022 reflected the following: Policy Statement: Standard precautions are used in the care of all residents regardless of their diagnoses or suspected or confirmed infection status. Standard precautions presume that all blood, body fluids, secretions, and excretions (except sweat), non-intact skin and mucous membranes may contain transmissible infectious agents. Policy Interpretation and Implementation: 1. Standard precautions apply to the care of all residents in all situations regardless of suspected or confirmed presence of infectious diseases. Standard precautions include the following practices: 1. Hand hygiene: a. Hand hygiene refers to handwashing with soap (antimicrobial or non-antimicrobial) or the use of ABHR, which does not require access to water. b. Hand hygiene is performed with ABHR or soap and water: (1) before and after contact with resident. 675518 Page 7 of 7