Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hilltop Skilled Nsg & Rehab during CMS and state inspections, most recent first.
A resident with cognitive impairment and a diagnosed UTI returned from the hospital with orders for Cephalexin 500 mg every eight hours, but the antibiotic was not started until several days later despite available backup and emergency pharmacy options, while facility leadership reported holding the medication pending urine C&S results that had already been completed and were obtainable from the hospital. During observation, two CNAs assisted this resident with toileting but did not provide front perineal cleansing afterward, even though the resident required maximum assistance with toileting and hygiene.
The facility failed to provide palatable, attractive meals at safe and appetizing temperatures, as evidenced by Food Committee notes and multiple cognitively intact residents reporting that meals were often cold, overcooked, burned, soggy, or unrecognizable, with complaints about poor quality evening meals and refusal of simple preferences such as chocolate milk. Observations of a test tray showed mixed vegetables below appropriate temperatures, and a manager in training handled the food with bare hands while attempting to warm it. A dietary manager acknowledged multiple complaints about overcooked, unappealing, and cold food amid significant dietary staffing turnover.
Staff failed to prevent cross contamination during a lunch meal when a manager in training wiped her bare hands on her pants, then grasped a food thermometer by the shaft and used it repeatedly to check the internal temperature of fried chicken in multiple pans without cleaning her hands or the thermometer. She also used potholders that had been on a contaminated counter to handle the pans while cycling them in and out of the oven, affecting food prepared for all residents in the facility.
Surveyors found that several cognitively intact residents with complex cardiopulmonary conditions, including COPD, CHF, chronic respiratory failure, OSA, and use of devices such as BI-PAP, oxygen concentrators, nebulizers, and a pacemaker monitor, had these medical devices plugged into outlet strip extension cords rather than directly into wall outlets. In multiple rooms, several high-demand medical devices were connected to a single outlet strip or to multiple outlet strips, sometimes sharing the only available wall outlet with the resident’s bed. A maintenance leader acknowledged that plugging multiple medical devices into outlet strips could be a fire hazard, and the administrator confirmed that many residents relied on extension cords for their medical equipment and that the facility had no policy governing this practice.
A resident with advanced dementia and high fall risk attempted to stand unassisted from a wheelchair and fell, sustaining a left femoral neck fracture. The chair alarm, intended to alert staff, did not sound due to improper setup, as the pull-tab string was too long and failed to activate. Staff did not ensure the alarm was correctly placed and functioning, leading to the resident's fall and injury.
A resident with multiple medical conditions was affected when 60 tablets of Tramadol and two count sheets went missing due to an LPN not verifying the quantity of controlled medication received from the pharmacy. The discrepancy was discovered after a pharmacy refill was denied, and the DON confirmed that the reconciliation process was not followed, making it impossible to account for the missing medication.
The facility failed to provide meals at safe and appetizing temperatures, affecting several residents with specific dietary needs. Residents reported consistently receiving cold and inedible meals, with some missing meals entirely. Observations confirmed that meal carts were not plugged in, and meals were served on room-temperature plates, highlighting a systemic issue in maintaining meal quality.
A resident's mattress was found with smeared clumps of a white food substance over two days, indicating a failure in maintaining cleanliness. The resident, who has dementia and limb absences, was affected by this deficiency. Staff interviews revealed that mattresses are only cleaned during deep cleaning sessions, and CNAs did not wipe the mattress clean, leading to the observed issue.
The facility inaccurately encoded MDS assessments for two residents' dental conditions, failing to note issues with their dentures. Observations showed both residents had upper dentures falling while speaking, but the MDS inaccurately documented no issues and marked them as 'unable to examine.' The assessments were completed offsite by a former MDS Coordinator, contrary to the MDS Manual's requirement for in-person examinations.
The facility failed to develop comprehensive care plans for two residents with denture problems, as their MDS assessments did not document any issues with denture fit, and their care plans lacked focus on denture care. The MDS assessments were completed offsite by a former coordinator, leading to the omission of denture issues. The dental CAA was not triggered, contrary to the MDS Manual's guidelines for individualized care planning.
A facility failed to document a recapitulation of stay for a resident who required maximum assistance and had multiple medical diagnoses, including COPD and diabetes. The resident's discharge plan had a blank section for this information, and the facility's administrator confirmed the lack of documentation and absence of a policy for completing such records.
A resident with multiple medical conditions requiring assistance for showering did not receive adequate care, missing several scheduled showers. The resident reported feeling unsafe due to a CNA's refusal to assist or leaving them unattended, leading to fewer showers than scheduled. The DON confirmed the resident's need for assistance and the facility's procedure to not leave residents unattended.
Three residents in the facility had their medical equipment improperly plugged into extension cords due to insufficient wall outlets. A resident's oxygen concentrator and two residents' electric beds were connected to extension cords, posing potential safety hazards. The Maintenance Director confirmed that medical equipment should be plugged directly into wall outlets, but the facility lacked a policy to enforce this.
The facility failed to obtain timely physician responses to pharmacist recommendations, affecting two residents. One resident experienced a delay in starting a prescribed antidiabetic medication due to a missed entry in the electronic medical record. Another resident's use of Lorazepam PRN without a stop date was not addressed by a physician despite multiple pharmacist recommendations. The facility's policy lacked specific timeframes for obtaining physician responses.
A resident with Hindu faith was served a meal containing pork, contrary to their religious dietary restrictions. The facility failed to document the resident's food preferences in their medical record, and no alternatives were offered. The Dietary Manager admitted to issues with maintaining a list of resident preferences, which is required by facility policy.
A resident with a documented onion allergy was served a meal containing onions, despite clear documentation of the allergy on their diet ticket. The resident, who has multiple medical conditions, did not consume the meal items containing onions, aware of the potential for severe illness. The Dietary Manager confirmed the oversight, acknowledging that the resident should not have been served onions, as per facility policy.
The facility failed to document evaluations for cognitively impaired residents' capacity to consent to intimate relationships. Two residents with severe cognitive impairment were observed engaging in intimate behavior without formal assessments of their consent capacity. The facility's policy lacked guidelines for documenting and maintaining these evaluations, affecting additional residents.
The facility failed to protect two residents, both with severe cognitive impairment due to dementia, from sexual abuse. An LPN observed inappropriate contact between the residents but did not intervene, assuming it was consensual. Despite their friendly interactions, no formal assessments were conducted to evaluate their capacity to consent, leading to a deficiency in safeguarding the residents.
The facility did not include documentation of an intimate relationship and privacy needs in the care plans of two residents. A nurse observed intimate behavior between the residents but did not act, assuming it was consensual. The facility's policy requires such documentation, but it was missing from the care plans.
A resident with cognitive impairment engaged in inappropriate sexual behavior towards two other residents, causing emotional distress and discomfort. Additionally, a staff member verbally abused another resident, leaving him feeling isolated and afraid. The facility failed to protect these residents from abuse, as required by their policy.
A resident with moderate cognitive impairment exhibited inappropriate sexual behaviors towards two cognitively intact residents. Despite these behaviors, the resident was not placed on continual observation immediately, leading to further incidents of inappropriate touching. The affected residents expressed feelings of vulnerability and discomfort, avoiding shared areas to stay away from the resident. The facility's administrator acknowledged the oversight in monitoring, which left residents at risk.
Two residents were involved in a physical altercation, which was not reported to the facility's Administrator or proper authorities as required by the facility's 'Abuse Policy'. Despite one resident being cognitively intact and reporting the incident to a CNA, the facility failed to document or act on the allegation, resulting in a deficiency.
Delayed UTI Antibiotic Therapy and Inadequate Perineal Care
Penalty
Summary
The deficiency involves a cognitively impaired resident who required maximum assistance with toileting and returned from the hospital with a diagnosis of urinary tract infection (UTI) and physician orders for Cephalexin 500 mg by mouth every eight hours for ten days. Nursing documentation on the day of return noted the UTI diagnosis and the antibiotic order, and the hospital discharge instructions also specified Cephalexin 500 mg every eight hours. However, the Medication Administration Record shows that Cephalexin was not initiated until six days later, despite the facility having a backup medication dispenser and access to an after-hours/emergency pharmacy for newly ordered medications. The Assistant DON/Infection Preventionist stated that the expectation was for immediate antibiotic treatment for infections, but reported that the antibiotic was held pending urine culture and sensitivity (C&S) results and that staff had difficulty obtaining those results from the hospital, even though the C&S was documented as completed two days after the resident’s return. In addition to the delay in antibiotic treatment, surveyors observed that two CNAs assisted the resident to the toilet and, after toileting, did not cleanse the resident’s front perineal area. The resident’s MDS documented that the resident was cognitively impaired and required maximum assistance with toileting, indicating dependence on staff for appropriate perineal care. The ADON/IP reported that the facility believed it could not receive laboratory results on weekends and that staff had left a message with the hospital requesting C&S results, but were unaware the results were already completed. In contrast, a hospital Release of Information representative stated that when facilities call for laboratory results, they are sent immediately by fax with same-day turnaround, indicating that timely results were available when requested.
Failure to Provide Palatable, Properly Prepared and Tempered Meals
Penalty
Summary
The facility failed to ensure food and drink were palatable, attractive, and served at safe and appetizing temperatures for its 64 residents. Food Committee Meeting Minutes documented ongoing concerns, including broccoli soup that tasted scorched and was not mixed well, tomato soup that was watered down, and general dissatisfaction with evening meals, which were described as not good. Multiple cognitively intact residents reported that food was often cold, inedible, and difficult to identify. One resident stated that while the meal on the day of observation looked and tasted good, this was a welcome surprise because the food was usually awful, cold, and sometimes unrecognizable. Another resident described the food as atrocious, reporting soggy french fries, burned food with black crust, dry and leathery chicken, dried-out bread, pasta that was either mushy or crunchy, and meals that were cold and unappealing, even when ordered from the alternative menu. This resident also reported being told that chocolate milk was a luxury and too extravagant and expensive to provide. A third resident reported a major problem with the kitchen not serving hot, appetizing, and tasty meals, and provided photographs of severely burned garlic toast with one side white and the other side entirely black with a thick layer of butter, a ground red ball of food identified as lasagna with only one visible noodle piece, and a supposed chicken pot pie served as mixed vegetables in gravy on a plate without any crust. During a test tray observation, a manager in training recorded food temperatures showing mixed vegetables at 110–125 degrees and used bare hands to push the vegetables together in an attempt to increase their temperature, stating they were not at the right temperature and felt cold. The Certified Dietary Manager reported multiple resident complaints of overcooked, unappealing, and cold food, along with significant staffing turnover and kitchen concerns prior to her arrival.
Cross Contamination During Hot Food Temperature Checks
Penalty
Summary
The facility failed to prevent cross contamination during meal service when a manager in training handled a food thermometer and other items in an unsanitary manner while checking the internal temperature of fried chicken prepared for 64 residents. During the lunch meal, which included fried chicken, mashed potatoes with gravy, creamed corn, a drink, and banana pudding, the manager in training determined the fried chicken was not at a high enough internal temperature to serve, then wiped her bare hands on her pants and picked up a thermometer by the shaft with her palm and fingers making full contact. She used this contaminated thermometer to test multiple pieces of chicken in a full pan, then used potholders that were laying on a contaminated counter to return that pan to the oven and remove a second pan of chicken. She again picked up the thermometer with her palm and fingers and used the same contaminated thermometer to test additional pieces of chicken from the second pan, repeating this process with both pans two more times until the internal temperature was safe to serve, without cleaning her hands or the thermometer between uses. The daily midnight census documented that 64 residents resided in the facility at the time of this meal service, and the contaminated thermometer and potholders were used in the preparation of food intended for these residents.
Improper Use of Extension Cords for Multiple Medical Devices
Penalty
Summary
The facility failed to ensure a safe physical environment by allowing multiple residents to use outlet strip extension cords for essential medical equipment instead of direct wall outlets. One cognitively intact resident with obstructive sleep apnea, chronic respiratory failure, heart failure, and atrial fibrillation had a nebulizer machine, oxygen concentrator, and BI-PAP machine all plugged into an outlet strip extension cord, which was then plugged into the single wall outlet in the room, along with the resident’s bed. Another cognitively intact resident with asthma, morbid obesity, atrial fibrillation, pericardial effusion, obstructive sleep apnea, heart failure, cardiomyopathy, chronic respiratory failure, and hypoxia had a pacemaker monitor and nebulizer machine plugged into an outlet strip extension cord attached to the wall; this resident commented that it looked like a fire hazard. A third cognitively intact resident with chronic respiratory failure, obstructive sleep apnea, tachycardia, and COPD had a BI-PAP and nebulizer machine plugged into one outlet strip extension cord connected to a wall outlet, while an oxygen concentrator was plugged into a separate outlet strip extension cord behind a recliner. A fourth cognitively intact resident with obstructive sleep apnea, COPD, malignant neoplasm of bronchus and lung, pulmonary fibrosis, emphysema, and chronic pulmonary edema had an oxygen concentrator plugged into an outlet strip extension cord and reported sometimes putting on or taking off the nasal cannula but not handling the plugs. The Maintenance Director stated that room outlets were being changed to hospital-grade circuit breaker types over time and acknowledged that plugging multiple medical devices requiring higher electrical draw into an outlet strip could be a fire hazard. The Administrator stated that multiple residents with multiple medical devices were using extension cords because that was the only option and confirmed the facility did not have a policy for the use of medical devices plugged into extension cords.
Failure to Properly Implement Fall Interventions Resulting in Resident Injury
Penalty
Summary
The facility failed to properly implement fall interventions for a resident with advanced dementia, poor balance, and a history of impulsiveness. The resident, who was at high risk for falls and required substantial assistance for transfers, attempted to stand up unassisted from her wheelchair and fell. At the time of the fall, the resident's chair alarm did not sound because the pull-tab alarm string was too long and remained attached to her shirt and the magnetic tab, preventing activation. Staff were required to ensure the alarm was properly placed and functioning each shift, but this was not done effectively, resulting in the alarm failing to alert staff as the resident attempted to stand. Following the fall, the resident complained of pain and was found to have sustained a mildly impacted non-displaced left femoral neck fracture. The resident's care plan included multiple fall interventions, such as a low bed, fall mats, a scoop mattress, anti-rollbacks on her wheelchair, and a pull-tab alarm, all intended to address her lack of safety awareness and high fall risk. Despite these interventions being documented, the improper setup of the alarm directly contributed to the resident's fall and subsequent injury.
Failure to Reconcile Controlled Medication Results in Missing Tramadol
Penalty
Summary
The facility failed to protect a resident's right to be free from misappropriation of their medication, specifically Tramadol, by not following established procedures for receiving and reconciling controlled substances. According to the facility's policies, controlled substances are to be verified upon receipt by both the receiving nurse and the individual delivering the medication. However, on the date in question, the nurse who received the delivery did not verify the quantity of Tramadol tablets received and simply signed the paperwork before passing the medication to another nurse. As a result, 60 tablets of Tramadol and two corresponding count sheets were found to be missing, and the discrepancy was only discovered when the pharmacy denied a refill request, citing a recent delivery. The resident involved had medical diagnoses including depression, anxiety, osteomyelitis, and a history of breast cancer, and had a physician's order for Tramadol 50 mg to be administered four times daily. Review of the medication administration records indicated that all doses were documented as given according to the order, but the lack of proper reconciliation and missing count sheets made it impossible to account for all the medication. The Director of Nursing confirmed the failure to follow the reconciliation process and was unable to determine what happened to the missing medication.
Deficiency in Meal Temperature and Palatability
Penalty
Summary
The facility failed to provide palatable and appropriately temperature-controlled meals to residents, as evidenced by multiple complaints and observations. Resident Council Minutes from July to September 2024 documented ongoing concerns about cold and sometimes burned food. The facility acknowledged these issues but did not implement effective solutions, as evidenced by the dietary manager's admission of inadequate equipment to maintain food temperatures. Several residents, including those with specific dietary needs due to medical conditions, were affected by these deficiencies. For instance, a resident with heart failure and end-stage renal disease reported consistently receiving cold meals and missing a meal entirely after dialysis. Another resident with severe protein-calorie malnutrition and chronic kidney disease received meals that were not in line with their dietary restrictions, such as being served a cold bologna sandwich instead of a heart-healthy meal. Observations on specific dates revealed that meal carts were not plugged in to maintain warmth, and meals were served on room-temperature plates. Residents consistently reported meals being cold, inedible, or not meeting their dietary needs. The dietary manager confirmed the lack of necessary equipment to serve warm meals, indicating a systemic issue in the facility's ability to provide adequate nutrition to its residents.
Failure to Maintain Cleanliness of Resident's Mattress
Penalty
Summary
The facility failed to maintain the cleanliness of a resident's mattress, affecting one resident out of 24 reviewed for environmental cleanliness. The resident, identified as R3, has medical conditions including Dementia and the acquired absence of both legs, one above the knee and the other below. On two separate occasions, surveyors observed smeared and mounded clumps of an unidentified white food substance resembling cake at the foot end of R3's mattress. The residue remained on the mattress over a period of two days, indicating a lack of proper cleaning. Interviews with facility staff revealed that the housekeeping staff only clean mattresses during deep cleaning sessions, which occur once daily for one resident room. The Certified Nursing Assistant (CNA) mentioned that CNAs and nurses have access to sanitizing bleach wipes but did not confirm a regular cleaning schedule for mattresses on residents' shower days. The Housekeeping Supervisor confirmed that the CNAs had brushed off the mattress on the resident's shower day but did not wipe it clean, leading to the observed deficiency.
Inaccurate MDS Assessments for Dental Conditions
Penalty
Summary
The facility failed to accurately encode the Minimum Data Set (MDS) assessments concerning dental conditions for two residents. During observations, both residents were noted to have issues with their upper dentures falling down to their lower lips while speaking, requiring them to push the dentures back into place with their tongues and lower lips. Despite these observations, the MDS assessments for both residents inaccurately documented that they had no broken or loosely fitting dentures and marked them as 'unable to examine.' The MDS Coordinator revealed that the assessments were completed by a former MDS Coordinator who worked offsite and did not conduct in-person examinations, leading to the 'unable to examine' coding. The MDS Manual specifies that a proper dental and oral assessment requires a physical examination using a gloved finger and light source, and dentures should be inspected for cracks, chips, and cleanliness. The manual also states that the 'unable to examine' code should only be used for uncooperative residents, which was not the case for the residents in question.
Failure to Address Denture Issues in Care Plans
Penalty
Summary
The facility failed to develop a comprehensive care plan for residents experiencing denture problems, affecting two residents out of three reviewed for dental issues. On separate occasions, both residents were observed with upper dentures falling down to their lower lips while speaking, requiring them to push the dentures back into place with their tongues and lower lips. Despite these observations, the residents' Comprehensive Minimum Data Sets (MDS) did not document any issues with broken or loosely fitting dentures, and their care plans lacked any focus on denture fit or cleaning care. The MDS Coordinator revealed that the MDS assessments were completed by a former coordinator who worked offsite and was unable to examine the residents directly, leading to the omission of denture issues in the assessments. The facility's failure to address these denture problems in the care plans was further compounded by the fact that the dental Care Area Assessment (CAA) was not triggered in Section V of the MDS. The MDS Manual emphasizes the importance of ensuring proper denture fit and care for individualized care planning, which was not adhered to in these cases.
Failure to Document Recapitulation of Stay for Discharged Resident
Penalty
Summary
The facility failed to complete a recapitulation of stay for a resident who was reviewed for discharge. The resident, who was cognitively intact, required maximum assistance with activities such as toileting, bathing, dressing, personal hygiene, and transfers. The resident had multiple medical diagnoses, including Chronic Obstructive Pulmonary Disease (COPD), repeated falls, amnesia, intervertebral disc degeneration, benign prostatic hyperplasia, obstructive sleep apnea, acute respiratory failure with hypoxia, and diabetes mellitus type II. Despite these needs and conditions, the resident's electronic medical record did not document a completed recapitulation of stay, and the discharge plan and instruction report had a blank section for this information. The facility's administrator acknowledged the absence of this documentation and stated that there was no policy in place for completing a resident's recapitulation of stay.
Inadequate Shower Assistance for Resident
Penalty
Summary
The facility failed to provide safe and adequate assistance with showers to a dependent resident, identified as R39, who was reviewed for Activities of Daily Living. R39 has multiple medical diagnoses, including Lumbar Spondylopathies, Spinal Cord Injury of the Lumbar Region, Neuromuscular Dysfunction of the Bladder, Depression, Left and Right Foot Drop, and Neurogenic Bowel. R39 is cognitively intact and requires varying levels of assistance for showering and dressing, as documented in the Minimum Data Set. The care plan specifies that R39 needs one-person staff assistance for bathing and is at risk for falls, necessitating observation for unsteady gait and balance. Despite being scheduled for showers twice a week, records show that R39 missed eight out of twenty scheduled showers over a two-month period. R39 reported feeling unsafe and uncomfortable due to inadequate assistance from a specific CNA, identified as V8, who either refused to assist or left R39 unattended in the shower room. This lack of assistance led R39 to refuse showers when V8 was assigned, resulting in R39 receiving only about one shower per week instead of the scheduled two. The Director of Nurses confirmed that staff should never leave residents unattended in the shower and that R39 requires assistance due to being a fall risk. The facility's procedure mandates that staff stay with residents throughout the shower and document the process in the resident's electronic health record, which was not consistently followed in R39's case.
Improper Use of Extension Cords for Medical Equipment
Penalty
Summary
The facility failed to ensure that resident medical equipment was properly utilized, leading to potential safety hazards for three residents. Resident 8, who has multiple medical conditions including chronic respiratory failure and dependence on supplemental oxygen, was observed using an oxygen concentrator plugged into a pink extension cord instead of a wall outlet. This was done due to a lack of sufficient wall outlets in the room, as stated by the resident. The Maintenance Director later confirmed that the oxygen concentrator should not be plugged into an extension cord. Similarly, Resident 18, who is cognitively intact and has several medical diagnoses including chronic congestive heart failure and epilepsy, had their bed plugged into a power strip nailed to the wall. The resident mentioned the need to use an extension cord due to insufficient wall outlets. Additionally, Resident 42's electric bed was also plugged into an extension cord power strip, along with a personal refrigerator. The Maintenance Director acknowledged that all resident beds and medical equipment should be plugged directly into wall outlets to prevent potential fire hazards. The facility lacked a policy explicitly stating that medical equipment should not be plugged into extension cords, as noted by the Administrator.
Failure to Obtain Timely Physician Responses to Pharmacist Recommendations
Penalty
Summary
The facility failed to obtain timely physician responses to pharmacist recommendations and did not develop a policy with specific timeframes for the monthly medication regimen reviews. This deficiency affected two residents. For one resident, R16, there was a delay in starting a prescribed antidiabetic medication, Semaglutide (Rybelsus), due to a missed entry in the electronic medical record. The consultant pharmacist identified the missing medication order and recommended clarification with the physician, but the physician did not sign off on this recommendation until nine days later. The Director of Nursing acknowledged that the admitting nurse may have overlooked the medication and that a second nurse should have reviewed the admission orders to prevent such errors. For another resident, R44, the facility did not obtain physician responses to multiple pharmacist recommendations regarding the use of Lorazepam PRN without a stop date. Regulations require a physician to document a rationale for continued use of PRN medications beyond 14 days. Despite receiving three separate recommendations from the consultant pharmacist, none were signed or addressed by a physician. The Director of Nursing noted that the resident was receiving hospice services but could not find any physician response to the recommendations. The facility's policy did not specify timeframes for obtaining physician responses to pharmacist recommendations.
Failure to Honor Resident's Religious Dietary Preferences
Penalty
Summary
The facility failed to honor a resident's food preferences, specifically related to religious dietary restrictions. The resident, who is of Hindu faith, was served a meal containing pork, which is against their religious beliefs. The resident's electronic medical record did not include a food preferences interview, and their nutritional care plan lacked a focus area, goal, or interventions prior to a specific date. The resident expressed that no staff offered alternatives for the meal, and they typically do not request alternatives when served food they cannot eat due to religious reasons. The Dietary Manager acknowledged that there were issues with documenting resident preferences and that no list of preferences had been maintained for several months. The facility's policy requires that food preference interviews be entered into the medical record and that tray assembly tickets reflect diet orders, allergies, intolerances, and preferences. However, this process was not followed, leading to the resident being served inappropriate food. The Dietary Manager indicated plans to address these issues by updating diet slips for all residents.
Failure to Adhere to Resident's Documented Food Allergies
Penalty
Summary
The facility failed to provide meals consistent with a resident's documented allergies, leading to a deficiency in meal service. A resident, identified as R6, who has multiple medical diagnoses including Diabetes Mellitus Type II and allergies to several substances including onions, was served a meal containing onions. Despite the resident's diet ticket clearly indicating an allergy to onions, the lunch meal included macaroni salad and spinach with pieces of onion. The resident did not consume these items, aware of the potential adverse reaction, and expressed that consuming onions would result in severe illness requiring hospitalization. The Dietary Manager acknowledged the oversight, confirming that the resident's diet ticket documented the onion allergy and that onions should not have been served. The facility's policy on Food and Nutrition Services requires that food preferences and allergies be documented and adhered to during meal preparation and service. This incident highlights a failure in the facility's adherence to its own policy, resulting in a potential risk to the resident's health.
Failure to Document Consent Capacity in Cognitively Impaired Residents
Penalty
Summary
The facility failed to document evaluations to determine the capacity of cognitively impaired residents to consent to a known sexual relationship. This deficiency was identified during a survey where it was found that the facility did not have a developed policy on intimate resident behavior that included criteria for initial evaluation and the frequency of evaluating a cognitively impaired resident's capacity to consent. The facility's policy also lacked specifications on where and how these evaluations and determinations would be documented and maintained. This failure affected two residents, both diagnosed with dementia and rated as severely cognitively impaired, and had the potential to affect 22 additional cognitively impaired residents. The report details specific incidents involving two residents, both with severe cognitive impairment, who were observed engaging in intimate behavior. Staff members, including CNAs and an LPN, witnessed these interactions but did not take action due to the belief that the interactions were consensual. However, there was no formal documented evaluation of the residents' capacity to consent to such activities. Interviews with the residents' POAs and facility staff revealed differing opinions on the residents' ability to consent, but no formal assessments had been conducted to support these opinions. The facility's policy on intimate resident behavior was found to be lacking in specific guidelines for documenting and maintaining evaluations of residents' capacity to consent to intimate relationships. The policy did not specify the frequency of these evaluations, and there was no documentation available during the survey to demonstrate that such evaluations had been conducted. This oversight in policy and documentation has the potential to affect a significant number of cognitively impaired residents within the facility.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to ensure that residents were free from sexual abuse, as evidenced by an incident involving two residents, R1 and R2, both diagnosed with dementia and rated as severely cognitively impaired. On a specific date, a Licensed Practical Nurse (LPN) observed R1 with his genitals exposed while R2 was touching them. Despite witnessing this, the LPN did not intervene, believing the interaction to be consensual based on the residents' previous interactions. However, there were no documented assessments in the residents' medical records to confirm their ability to consent to sexual relationships. Further interviews with staff, including Certified Nursing Assistants (CNAs) and the Director of Nursing (DON), revealed that there was a general assumption of consent between R1 and R2 due to their friendly behavior and history of knowing each other from a previous nursing home. However, none of the staff, including the Social Services Director, had conducted formal evaluations to assess the residents' capacity to consent to sexual activity. This lack of formal assessment and documentation contributed to the facility's failure to protect the residents from potential abuse.
Failure to Document Intimate Relationship in Care Plans
Penalty
Summary
The facility failed to develop care plans for two residents to include their intimate relationship and the need for privacy. This deficiency was identified during interviews and record reviews. A Licensed Practical Nurse (V7) observed one resident with exposed genitals while another resident was engaging in intimate behavior with them. Despite witnessing this, V7 did not intervene, believing the relationship to be consensual. A Certified Nursing Assistant (V5) also reported observing intimate behavior between the two residents. The facility's policy on Intimate Resident Behavior, Privacy, and Relationships requires documentation of issues or concerns related to intimacy and sexual expression in the residents' care plans. However, as of the time of the survey, neither resident had such documentation in their care plans.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from sexual and verbal abuse, as evidenced by multiple incidents involving a resident identified as R1 and other residents. R1, who was documented as moderately cognitively impaired, engaged in inappropriate sexual behavior towards residents R2 and R3. R2, who was cognitively intact, reported that R1 touched her breasts in the hallway, causing her emotional distress and discomfort. Despite being informed of the incident, R1 was allowed to return to the facility, leading R2 to feel unsafe and avoid shared areas. Similarly, R3, also cognitively intact, reported that R1 attempted to touch her breast on two separate occasions, which made her feel vulnerable and uncomfortable. In addition to the incidents involving R1, the facility also failed to protect resident R5 from verbal and mental abuse by a staff member, identified as V8, a Certified Nurse Aide (CNA). R5, who was cognitively intact and dependent on staff for assistance due to multiple medical conditions, reported that V8 used foul language and refused to assist him with his requests. R5 expressed fear of V8, as he was left unattended in his chair for hours during the night shift, feeling isolated and afraid to ask for further assistance. The facility's policy on abuse clearly prohibits any form of abuse, including sexual and verbal abuse, and emphasizes the residents' right to be free from such mistreatment. However, the facility's inaction in promptly addressing R1's inappropriate behavior and V8's verbal abuse towards R5 highlights a significant deficiency in protecting residents from abuse. The failure to implement immediate and effective measures to prevent further incidents contributed to the residents' feelings of fear, discomfort, and vulnerability.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect residents from inappropriate behaviors and sexual abuse by another resident, resulting in a deficiency. Resident 1, who was moderately cognitively impaired, exhibited inappropriate sexual behaviors towards other residents, including attempting to touch staff and residents inappropriately. Despite these behaviors, Resident 1 was not placed on continual observation immediately after the first incident involving Resident 3, who was cognitively intact. Resident 3 reported that Resident 1 attempted to touch her inappropriately twice, with the first attempt being witnessed by a Certified Nurse Aide. Resident 3 expressed feeling vulnerable and uncomfortable, choosing to avoid shared areas when Resident 1 was present. Resident 2, also cognitively intact, reported that Resident 1 rubbed his hands over her breasts after an earlier incident involving Resident 3. Resident 2 expressed distress and discomfort, stating that she felt unsafe and had to avoid Resident 1. The facility's administrator acknowledged that Resident 1 should have been placed on continual observation immediately after the first incident with Resident 3 to prevent further incidents. The failure to implement immediate protective measures left residents at risk of abuse, as Resident 1 was not adequately monitored or sent for evaluation after the initial inappropriate behavior.
Failure to Report Alleged Resident Abuse
Penalty
Summary
The facility failed to report an allegation of physical abuse between two residents to the Abuse Coordinator and the State Agency in a timely manner. Resident R5, who is cognitively intact, reported to a Certified Nurse Aide (CNA) that a couple of months ago, they had a fist fight with their roommate, R1. Despite this disclosure, the CNA did not report the incident to the facility's Administrator or any other appropriate authority. R5 expressed concerns about being roommates with R1 again due to the potential for further altercations. The facility's Administrator, V1, was unaware of the incident and stated that any allegations of abuse should be reported to them for further investigation. The facility's 'Abuse Policy' mandates the immediate reporting of all abuse allegations to the Administrator and timely notification to the proper authorities, including the Illinois Department of Public Health, Ombudsman, Local Police Department, Power of Attorney, and Physician. However, there was no documentation to show that R5's allegation was ever reported, indicating a failure in adhering to the facility's policy and state regulations.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 226 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Charleston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Charleston Rehab And Nursing | 6.9 mi | ★★★★★ | 21 | 0 |
| The Haven Of Arcola | 10.5 mi | ★★★★★ | 20 | 0 |
| Odd Fellow-rebekah Home | 13.6 mi | ★★★★★ | 20 | 0 |
| Palm Garden Of Mattoon | 14.9 mi | ★★★★★ | 36 | 1 |
| Mattoon Rehab & Hcc | 14.9 mi | ★★★★★ | 28 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.