Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Lodge Health And Rehabilitation Center during CMS and state inspections, most recent first.
Incorrect Meal Portioning and Recipe Preparation: Dietary staff prepared pureed cornbread stuffing and regular diet chopped buttered carrots in portions that did not match the facility recipes. One DS used a three-ounce scoop for pureed stuffing instead of the required four-ounce portion, and another DS served carrots and stuffing in one-ounce portions despite the recipe calling for four ounces. Staff later confirmed the meal recipes were not followed.
Food Storage and Labeling Deficiencies: Surveyors observed multiple opened food items in the kitchen without when-opened dates or labels, including deli meats, eggs, cheese, mayonnaise, mustard, lettuce, and pineapple. An expired juice item was also found in the refrigerator, and the walk-in freezer contained food stored directly on the floor along with an unlabeled item. Dietary and admin staff verified that opened foods should be dated and that food should not be stored on the freezer floor.
Failure to maintain resident dignity and privacy: A resident with severe cognitive impairment, schizophrenia, and total ADL dependence was observed sitting in a Broda chair with only a brief and shirt on, with her legs and brief visible to passersby and her blanket and call light fallen to her feet. Staff interviews confirmed residents were expected to be dressed, covered, and not exposed when out of bed.
Failure to revise a resident’s fall care plan after repeated falls. A resident with Parkinson’s disease, impaired gait and mobility, weakness, and moderate cognitive impairment had numerous falls while trying to toilet, reach items, or stand from a recliner. Staff repeatedly documented call-light education and reminders, but the care plan did not add new fall-prevention interventions after the ongoing falls, and at least one fall lacked a causal investigation.
Failure to place a rolled washcloth in a resident’s contracted hand. A resident with dystonia, dysphagia, TBI, and contractures was dependent on staff for all ADLs and had a care plan directing staff to place a rolled washcloth or carrot in his right hand as tolerated. During observation, his hands were clenched and no washcloth or carrot was in place, despite staff stating nursing was responsible for applying it.
Failure to investigate repeated falls and update the care plan: A resident with Parkinson’s disease, gait impairment, weakness, impaired cognition, and a history of repeated falls had numerous incidents while trying to transfer, toilet, or retrieve items without assistance. Staff repeatedly documented that the resident refused or failed to use the call light or ambulation device, and several falls were handled with education alone. The record also showed multiple falls without a causative-factor investigation and no new intervention added to the care plan.
A resident’s Lantus flex pen on the nurse treatment cart was observed without an opened date. An LPN verified insulin flex pens should be labeled and dated when opened, and an administrative nurse confirmed the pens should include the opened and expiration dates using a sticker provided by the facility.
Respiratory Equipment Not Stored Sanitarily: A resident's nasal O2 tubing, another resident's nebulizer mask, a CPAP mask, and another resident's nebulizer were observed stored in unsanitary ways, and one resident's uncovered O2 cannula and tubing were found lying on an oxygen tank valve and later rolled up under the concentrator handle while in use. Staff stated respiratory equipment not in use should be stored in a drawer or bag, and the facility policy required delivery devices to be covered in a plastic bag when not in use.
Incomplete PBJ Staffing Submission: The facility failed to submit complete and accurate PBJ direct care staffing data based on payroll and other verifiable records. CMS PBJ reports for multiple quarters showed excessively low weekend staffing and a one-star staffing rating, even though review of staffing and nursing hours showed adequate coverage. An Administrative Nurse stated salaried nurses did not clock in when they filled in, so their hours were not counted.
A resident with cognitive impairments and a high risk for elopement managed to leave the facility by chiseling open a window. Despite assessments indicating the risk, the facility failed to update the care plan with necessary interventions. The resident was found at a nearby store after crossing a busy highway, expressing to police that he felt held captive. The facility's lack of action placed the resident in immediate jeopardy.
The facility did not employ a full-time certified dietary manager, which is necessary to ensure adequate nutrition for residents. Dietary Staff BB, who was managing dietary services, was not certified, although they had started the certification classes. This was confirmed by Administrative Staff A. The facility's policy required the director of food and nutrition services to be qualified according to job descriptions and regulatory guidelines, but this requirement was not met, placing residents at risk for inadequate nutrition.
A facility failed to provide proper catheter care for several residents, leading to unsanitary conditions and increased risk of UTIs. Observations revealed catheter bags on the floor and inadequate care planning. Staff did not follow infection control protocols, and care plans lacked necessary interventions for catheter management.
The facility failed to ensure the Consultant Pharmacist identified and reported medication irregularities, leading to potential risks of inappropriate medication use. Several residents were affected, including those with unapproved medication indications, lack of monitoring parameters, and absence of physician responses to pharmacist recommendations. These deficiencies highlight the facility's failure to adhere to its medication regimen review policy.
The facility failed to ensure appropriate indications and documentation for psychotropic medications for several residents, leading to the risk of unnecessary medication use. One resident was prescribed multiple antidepressants and an antipsychotic without a gradual dose reduction or physician documentation. Another resident received alprazolam as needed for anxiety without a required stop date, and a third resident's medications were not subjected to a gradual dose reduction despite recommendations. Additionally, a resident was prescribed quetiapine without appropriate documentation, placing them at risk for unnecessary side effects.
A resident with urinary retention and an indwelling catheter was observed in the dining room with his catheter bag uncovered, visible to other residents. Despite the facility's policy to maintain resident dignity, staff failed to cover the bag, as confirmed by an administrative nurse. This oversight risked the resident's dignity.
A resident's room was found to have crinkled duct tape between the floor carpet seams, posing a trip hazard. Maintenance staff acknowledged the need for flooring replacement but had not submitted a requisition. An administrative nurse was initially unaware of the issue but later agreed it could be hazardous. The facility's policy requires preventative maintenance to ensure safety, which was not followed.
Two residents in an LTC facility experienced neglect and potential abuse due to inadequate care and improper handling. One resident was left unattended in the bathroom for an hour, with a CNA being rude and unhelpful. Another resident suffered a large bruise from an improper transfer using a gait belt instead of a Hoyer lift. Both incidents were not thoroughly investigated or reported to the State Agency, highlighting a failure in the facility's procedures to prevent and address neglect and abuse.
The facility failed to report allegations of abuse and neglect for two residents to the State Agency. One resident, with multiple medical conditions, reported a CNA being rude and not assisting her, while another resident with severe cognitive impairment was found with a large bruise, suspected to be from improper transfer. The facility did not conduct thorough investigations or report these incidents, violating their policies and placing residents at risk.
The facility failed to investigate allegations of abuse and neglect for two residents, placing them at risk of ongoing mistreatment. One resident reported a CNA being rude and not assisting her, while another resident was found with a large bruise possibly from improper transfer techniques. The facility did not conduct thorough investigations or report the incidents to the State Agency, violating their policies on abuse and neglect.
The facility failed to develop comprehensive care plans for three residents with indwelling urinary catheters, leading to uncommunicated care needs and potential risks. One resident's catheter bag was observed dragging on the floor, another's was lying on the floor, and a third's catheter tubing was not properly anchored. The care plans lacked necessary interventions despite the residents' medical histories and physician orders.
A resident with a history of stroke and rheumatoid arthritis had a Stage 4 pressure ulcer and required a foot cradle to prevent further skin breakdown. Despite an APRN's recommendation, the care plan was not updated to include this intervention until nearly two months later, leading to a delay in care. Staff acknowledged the oversight, which placed the resident at risk for impaired care.
A resident with vascular dementia and other conditions did not receive consistent bathing assistance as required by their care plan. Despite being independent in most activities of daily living, the resident needed help with bathing, which was not provided for extended periods. Observations showed poor hygiene, and staff confirmed the resident did not refuse showers, contrary to the facility's policy.
Two residents in an LTC facility experienced deficiencies in care related to non-pressure skin injuries. One resident developed a worsening skin abrasion due to improper use of a Hoyer lift sling, while another resident's toe injury went unreported to a physician, despite evident pain and drainage. These incidents highlight failures in adhering to care plans and communication protocols, placing residents at risk for further complications.
The facility failed to provide adequate pressure ulcer care and prevention for two residents. One resident, with a complex medical history, did not receive a pressure-relieving cushion or nutritional support, leading to a painful sore. Another resident, dependent on staff for all activities, had a Stage 4 pressure ulcer, but the facility delayed implementing recommended nutritional and pressure relief interventions. These failures placed both residents at risk for ongoing pressure injuries and complications.
A facility failed to provide range of motion (ROM) services to a resident with a history of CVA, hemiplegia, and rheumatoid arthritis, as outlined in her care plan. The resident was dependent on staff for all ADLs and mobility, and her care plan required daily ROM exercises. Observations and staff interviews confirmed that these services were not provided, placing the resident at risk for impaired mobility and decreased function.
A facility failed to provide necessary nutritional assessments and interventions for two residents, leading to continued weight loss and inadequate meal provision. One resident, with a history of weight loss and severe cognitive impairment, did not receive proper diet orders or supplements, and the RD and physician were not notified. Another resident on a pureed diet did not receive the full meal components as per the menu, despite RD recommendations. The facility's policies on weight loss interventions were not followed, placing residents at risk for further decline.
A resident with a history of mental health issues and multiple diagnoses, including major depressive disorder and bipolar disorder, did not receive the necessary mental health services at the facility. Despite expressing a need for mental health support and having a care plan in place, the resident's clinical record lacked evidence of such services being offered. The facility's failure to adhere to its Behavioral Health Services policy placed the resident at risk for unmet mental health care needs.
A resident with type 2 diabetes mellitus was not adequately monitored for blood sugar levels, as the care plan lacked parameters for physician notification of abnormal readings. Despite a high postprandial blood sugar level of 456 ml/dL, there was no evidence of physician notification or assessment, highlighting a deficiency in the facility's monitoring and communication protocols.
The facility failed to provide sanitary catheter care for three residents, leading to increased infection risk. Observations showed catheter bags placed on the floor and improper hand hygiene by staff. A CNA did not change gloves or wash hands after care, violating the facility's infection prevention protocols.
Incorrect Meal Portioning and Recipe Preparation
Penalty
Summary
The facility failed to provide residents with the correct nutritional dietary needs for meals prepared in the kitchen. During observation, Dietary Staff CC prepared pureed cornbread stuffing by placing one three-ounce scoop into a 12-ounce Bullet blender, blending it with milk, and dividing the mixture into two stainless steel steam table containers for five servings, even though the pureed recipe called for a four-ounce portion using a #8 scoop. At the same time, Dietary Staff BB served regular diet portions of chopped buttered carrots using a one-ounce portion-controlled scoop and cornbread stuffing using a one-ounce rounded scoop, although the regular diet buttered carrot recipe portion was four ounces. Activity Staff Z and Administrative Staff A later verified that the kitchen staff should have followed the meal recipes for the correct portion sizes of the buttered carrots and cornbread stuffing. The facility's Dining Manager 2026 Dining RD policy directed staff to serve four ounces of prepared pureed cornbread stuffing and regular diet chopped carrots of four ounces.
Food Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to store, prepare, and serve food in a sanitary condition for 66 residents who receive meals from the facility's kitchen. During an initial kitchen tour, surveyors observed multiple food items without open dates or labels, including a four-quart container of diced pineapples, deli-sliced ham and turkey, a sack of hard-boiled eggs, a gallon of liquid cheese, a gallon-sized tub of mayonnaise and mustard, and two bags of chopped lettuce. A quarter of lime juice with an expiration date of 12/01/25 was also found stored in the refrigerator. In the walk-in freezer, surveyors observed a box of chicken breast filets sitting directly on the freezer floor, an opened sack of French fries without an open date, and a small unlabeled bag of an unidentified item resting on the floor. Dietary staff verified that opened foods should have when-opened dates marked on the containers and that food should not be stored on the freezer floor. Administrative staff also verified that foods should have open dates and that foods were not to be stored on the freezer floor. The facility's policies documented required storage times for several food items and stated that opened food packages should be marked with the open date to determine when food should be discarded.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to ensure Resident 3 was covered while sitting in a Broda chair in her room. At 7:45 AM on 01/13/26, she was observed in the chair with only a brief and shirt on, with her legs and brief visible to residents walking past her room. A grey blanket with the call light attached had fallen down onto her feet, leaving her uncovered and the call light out of reach. The resident’s record documented schizophrenia, cognitive communication deficit, repeated falls, dysphagia, severely impaired cognition with a BIMS score of zero, and that she was rarely or never understood. Her MDS also documented impairment of her upper and lower body and need for staff assistance with all ADLs. The resident’s care area assessment identified her as requiring assistance with self-care and mobility and at risk for further decline in functional abilities, falls, contractures, isolation, pressure ulcers, and incontinence. Her care plan directed staff to approach her in a gentle, friendly, and unhurried manner and noted she would be able to communicate basic needs daily. During interviews, a CNA stated the resident should be dressed and groomed and that residents were expected to be dressed, covered, and not exposed to other residents. An LN stated residents should not be left uncovered and should be dressed or covered and not exposed. An administrative nurse stated residents should be dressed and groomed when out of bed and should never have their briefs exposed unless it was a behavior that had been care planned.
Failure to Revise Fall Care Plan After Repeated Falls
Penalty
Summary
The facility failed to revise A resident’s comprehensive care plan with new interventions after repeated falls and related status changes. The resident had diagnoses including unspecified abnormalities of gait and mobility, abnormal posture, muscle weakness, repeated falls, Parkinson’s disease, and a personal history of traumatic fracture. The annual MDS documented moderately impaired cognition, use of a walker and wheelchair, substantial to maximal assistance with toileting hygiene and dressing, dependence for footwear and walking 10 to 150 feet, partial/moderate assistance with transfers, frequent urinary incontinence, and two or more falls without injury. The resident’s CAA dated 11/08/25 triggered for falls due to multiple falls during the review period and documented risk for injury related to fall risk. The care plan dated 02/17/21 addressed limited physical mobility related to Parkinson’s disease and an actual fall with no injury related to unsteady gait, but the record showed repeated falls afterward. Progress notes documented falls when the resident tried to ambulate independently to the bathroom, turn on a power strip, reach items from the dresser or shelf, get briefs, check whether a chair pad was wet, stand up from the recliner, or move around during care activities. Several notes documented that the resident was reminded to use the call light, that the call light was within reach, and that staff encouraged him to request assistance. Despite the repeated falls on 01/31/25, 02/01/25, 05/16/25, 05/19/25, 06/15/25, 06/16/25, 08/02/25, 09/12/25, 09/19/25, 09/27/25, 10/08/25, 10/15/25, 11/11/25, 12/01/25, 12/04/25, and 12/13/25, the care plan did not add a new intervention to prevent further falls and injuries for those events. The record also documented that the facility failed to conduct a fall investigation for causal factors for at least one fall, and Administrative Nurse D later verified that repeated education to call for assistance had been ineffective and that there had been falls lacking a fall investigation with root cause analysis or a new intervention added to the care plan.
Failure to Place Rolled Washcloth in Resident’s Contractured Hand
Penalty
Summary
The facility failed to ensure Resident 41’s rolled washcloth or carrot was applied to his right hand as directed to help maintain range of motion and prevent wounds related to his contractures. Resident 41 had diagnoses including dystonia, dysphagia, traumatic brain injury, and contracture, and his MDS documented moderately impaired cognition, impairments of both the upper and lower body, and dependence on staff for all ADLs. His care area assessment identified him as at risk for further decline in functional abilities, falls, contractures, isolation, pressure ulcers, and incontinence, and his care plan directed staff to place a rolled washcloth or carrot in his right hand as tolerated. During observation, Resident 41 was seen lying on his side and later sitting in his Broda chair with his hands clenched in his lap, and no washcloth or carrot was in his right hand at either time. His right thumb had a dressing in place. A CNA stated restorative personnel would normally place the washcloth or carrot in his hand, and if it was missing, staff would tell the nurse. An LN stated it was the assigned nurse’s responsibility to place the washcloth or carrot in the resident’s right hand and that it should have been placed there. An administrative nurse also stated the washcloth should have been placed in his hand and that nursing was expected to do so.
Failure to investigate repeated falls and update the care plan
Penalty
Summary
The facility failed to ensure an area free from accident hazards and adequate supervision to prevent accidents for a resident with repeated falls. The resident had diagnoses including unspecified abnormalities of gait and mobility, abnormal posture, muscle weakness, repeated falls, Parkinson’s disease, and a personal history of traumatic fracture. The resident’s MDS documented moderately impaired cognition, use of a walker and wheelchair, substantial to maximal assistance needs for toileting hygiene and dressing, dependence for footwear and walking 10 to 150 feet, partial to moderate assistance with transfers, frequent urinary incontinence, and two or more falls without injury. The CAA identified the resident as at risk for fall-related injuries due to multiple falls during the review period. The resident experienced numerous falls in the room and bathroom while attempting to get up, transfer, retrieve clothing, snacks, briefs, chapstick, or other items without staff assistance. Several progress notes documented that the resident reported he was trying to do things independently, did not want to bother staff, or did not feel he needed help. In multiple incidents, staff found the resident on the floor with no injuries or minor injuries such as an abrasion or laceration. The record also documented that the resident often refused to use the call light or proper ambulation device, and staff repeatedly educated him to ask for assistance. The facility’s fall investigations repeatedly described the resident as non-compliant or independent and often concluded with continued education, monitoring, or consideration of a negotiated risk agreement. However, the record identified falls for which the facility did not conduct a causative-factor investigation, and the care plan lacked new interventions for several falls, including falls on 01/31/25, 02/01/25, 05/16/25, 05/19/25, 06/15/25, 06/16/25, 08/02/25, 12/04/25, and 12/13/25. On 01/13/26, Administrative Nurse D verified that frequent education to call for assistance had been ineffective, the resident continued to fall, and there had been falls that lacked a fall investigation with a root cause analysis or a new intervention added to the care plan.
Unlabeled Insulin Flex Pen
Penalty
Summary
The facility failed to label Resident 47’s insulin flex pen when it was initially opened for use. During observation of the North Hall nurse treatment cart, R47’s Lantus flex pen was found without an opened date. A license nurse verified that nurses should label and date insulin flex pens with the date opened, and an administrative nurse later confirmed that the pens should be labeled with the date opened and the date expired, stating that the nurses have a sticker for that information. The facility’s Medication Storage policy stated medications would be stored according to the manufacturer’s recommendations to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.
Respiratory Equipment Not Stored Sanitarily
Penalty
Summary
The facility failed to ensure oxygen saturation equipment was sanitized after each resident's use and failed to ensure several residents' respiratory devices were stored in a sanitary manner. During observations, R45's nasal oxygen tubing was found laid in his chair, R48's nebulizer mask hung over the bedside table, R2's CPAP mask was laid on his dresser, and R29's nebulizer was laid on her bedside table. R32 was observed with an uncovered oxygen cannula and tubing lying on the oxygen tank cylinder valve in the North Hall dining room while he ate lunch, and later his uncovered oxygen cannula and tubing were rolled up and placed under the oxygen concentrator handle in the same area. Staff interviews reflected expectations that respiratory equipment not in use should be stored in a drawer, bag, or marked bag, and that equipment should be rinsed, dried, and covered while drying. The facility's Oxygen Storage policy stated oxygen tubing and mask/cannula should be changed weekly and as needed if soiled or contaminated, and delivery devices should be kept covered in a plastic bag when not in use.
Incomplete PBJ Staffing Submission
Penalty
Summary
The facility failed to submit complete and accurate direct care staffing information through Payroll-Based Journal (PBJ) based on payroll and other verifiable and auditable data. For FY 2025 Q1, Q2, and Q3, the CMS PBJ report showed excessively low weekend staffing and a one-star staffing rating, while review of the facility’s staffing and nursing hours for those quarters showed adequate staffing coverage. During interview on 01/12/26 at 02:30 PM, Administrative Nurse D stated that the appropriate number of staff had worked, but salaried nurse staff did not clock in, so their hours were not counted when they filled in for staff. Administrative Nurse D also verified that the facility always had nurse and aide coverage.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to identify and implement necessary interventions to prevent an elopement for a resident who was cognitively impaired and at high risk for elopement. Despite assessments on two occasions indicating the resident's high risk for wandering or elopement, the facility did not update the resident's care plan to include interventions or alert staff to the elopement risk. On the day of the incident, the resident was last seen at 7:30 AM, and by 10:30 AM, the facility was informed by a community member that the resident was outside the facility. The resident had managed to open a window by chiseling wooden blocks with a butter knife and exited the facility, crossing a busy highway to reach a nearby store. The resident, who had a history of frontotemporal neurocognitive disorder, dementia, depression, and both homicidal and suicidal ideations, was found at a farm store 0.3 miles away from the facility. The resident had to navigate a busy highway and steep ditches to reach the store. Upon being found, the resident expressed to a police officer that he felt the facility was holding him captive. The resident was returned to the facility with the assistance of law enforcement but refused further assessment upon return. The facility's failure to implement interventions and provide adequate supervision placed the resident in immediate jeopardy. The resident's care plan lacked documentation of interventions aimed at preventing wandering or elopement until after the incident occurred. The facility's policy on elopement and wandering residents was not effectively followed, as the resident's risk was not adequately addressed in their care plan prior to the elopement incident.
Removal Plan
- R1 was placed on one-to-one with staff.
- The facility notified R1's primary care physician and responsible party of the situation.
- A new wandering assessment was completed for R1.
- The elopement book was reviewed and updated.
- R1's Care Plan was updated.
- An ad hoc meeting was held with the medical director.
- Maintenance secured the windows in R1's room.
- Maintenance checked all of the windows in the facility to ensure stoppers were in place.
- Education was provided to all staff on elopement and abuse, neglect, and exploitation.
Lack of Certified Dietary Manager in Facility
Penalty
Summary
The facility failed to employ a full-time certified dietary manager, which is a requirement for ensuring adequate nutrition for residents. At the time of the survey, the facility had a census of 59 residents, with a sample of 19 residents being reviewed. During observations and interviews, it was confirmed that Dietary Staff BB, who was responsible for managing the dietary services, was not a certified dietary manager. Although Dietary Staff BB had started the certified dietary manager classes, they had not yet obtained the certification. Administrative Staff A also verified that Dietary Staff BB did not possess the necessary certification. The facility's Director of Food Policy, revised on 07/02/21, required that the director of food and nutrition services be qualified according to the job description and regulatory guidelines. The absence of a certified dietary manager placed the residents at risk for inadequate nutrition.
Deficient Catheter Care Practices in LTC Facility
Penalty
Summary
The facility failed to provide sanitary indwelling urinary catheter care for several residents, placing them at risk for urinary tract infections and catheter-related injuries. Resident 55, who had multiple diagnoses including type two diabetes mellitus and dementia, was observed with a catheter drainage bag dragging on the floor under the wheelchair and resting on the floor mat next to the bed. The care plan for Resident 55 lacked interventions related to the indwelling catheter, and the resident had a history of UTIs treated with antibiotics. Resident 17, with a history of UTIs and other medical conditions, was observed with a catheter drainage bag lying on the floor, not attached to the bed. The care plan for Resident 17 also lacked directions for catheter care, despite the resident's history of UTIs. Staff confirmed that the catheter bag should not be on the floor and acknowledged the oversight in care planning. Resident 54 was observed with a catheter bag placed on the floor during care, and the staff member failed to change gloves or wash hands after providing catheter care. This was against the facility's infection prevention protocols. Additionally, Resident 20's care plan lacked information about the urinary catheter, and there was no anchor for the catheter tubing, which could lead to pulling or displacement. The facility's failure to ensure proper catheter care and documentation placed these residents at risk for complications.
Medication Review Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure that the Consultant Pharmacist (CP) identified and reported medication irregularities for several residents, leading to potential risks of inappropriate medication use. For one resident, the CP did not report the use of multiple antidepressants prescribed for anxiety, which is not an approved indication. The resident's medical record lacked evidence of a physician's response to the CP's recommendations, placing the resident at risk for inappropriate use of psychotropic medications. Another resident's care plan lacked parameters for blood sugar monitoring, and the CP failed to identify and report this omission, risking complications related to insulin use. Additionally, the facility did not ensure that the CP identified and reported the lack of an end date for a PRN antianxiety medication for another resident. This oversight placed the resident at risk for inappropriate use of psychotropic medications. Furthermore, the CP recommended a gradual dose reduction for a resident's psychotropic medications, but the facility failed to ensure the physician reviewed and acknowledged these recommendations, leaving the resident at risk for unnecessary medication use. The facility also failed to ensure the CP identified and reported the lack of an appropriate indication for the use of an antipsychotic medication for another resident. The resident's medical record did not contain a documented physician rationale for the ongoing use of the medication, which could lead to unnecessary medication use and adverse side effects. These deficiencies highlight the facility's failure to adhere to its medication regimen review policy, which requires monthly reviews by a licensed pharmacist and communication of any irregularities within 72 hours.
Inadequate Documentation and Indication for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that several residents' psychotropic medications had appropriate indications and documentation, leading to the risk of unnecessary medication use. Resident 10 was prescribed multiple antidepressants and an antipsychotic without a gradual dose reduction or physician documentation indicating that such a reduction was clinically contraindicated. The pharmacy recommended reassessment of the indications for mirtazapine and hydralazine, as they were not FDA-approved for the conditions they were prescribed for, but there was no evidence of a physician response. Resident 55 was prescribed alprazolam as needed for anxiety without a required stop date, and the medication was administered multiple times over several months. The pharmacy noted the lack of an FDA-approved indication for alprazolam, but the physician only responded with the indication of anxiety, without addressing the need for a stop date. This oversight placed the resident at risk for unnecessary psychotropic medication use and related side effects. Resident 20's psychotropic medications, including Buspar, duloxetine, and zolpidem, were not subjected to a gradual dose reduction despite recommendations from the consultant pharmacist. The physician did not provide a risk versus benefit rationale for the continued use of these medications. Similarly, Resident 38 was prescribed quetiapine without appropriate documentation of the indication or non-pharmacological interventions attempted, placing the resident at risk for unnecessary side effects.
Failure to Maintain Resident Dignity by Not Covering Urinary Catheter Bag
Penalty
Summary
The facility staff failed to treat Resident 54 with dignity by not covering his urinary catheter bag with a privacy bag, leaving the urine visible to other residents and guests. This incident was observed when Resident 54, who had a diagnosis of urinary retention and an indwelling urinary catheter, was seen ambulating from his room to the dining room with the catheter bag hanging on the side of his walker without a privacy cover. The resident, who had intact cognition as indicated by a BIMS score of 15, sat at the dining room table with the urine collection bag uncovered, visible to 12 other residents. The facility's policy on promoting and maintaining resident dignity, revised in November 2017, requires staff to protect and promote resident rights and treat each resident with respect and dignity. Despite this policy, the staff did not adhere to the expected practice of ensuring the urinary catheter bag was covered, as confirmed by an interview with Administrative Nurse D. This oversight placed Resident 54 at risk for impaired dignity, as the facility failed to maintain the resident's privacy and dignity in accordance with their own policy.
Unsafe Environment Due to Crinkled Duct Tape
Penalty
Summary
The facility failed to provide a safe environment for a resident when staff placed crinkled duct tape between the floor carpet seams in the resident's room. This was observed on two occasions, with the duct tape running from the bed to the south wall and crinkled up approximately one foot in the middle. Maintenance staff verified the issue and acknowledged that the flooring needed replacement, but had not yet submitted a requisition to the administrator. An administrative nurse was initially unaware of the issue but later agreed that the duct tape could pose a trip hazard. The facility's Resident Environmental Quality Policy, revised in November 2017, requires preventative maintenance schedules to be followed to maintain a safe environment, which was not adhered to in this instance.
Neglect and Abuse of Residents Due to Inadequate Care and Improper Handling
Penalty
Summary
The facility failed to protect two residents, R11 and R18, from neglect and abuse, as evidenced by incidents involving inadequate care and improper handling. R11, who had multiple medical conditions including cerebral infarction, COPD, and dementia, was left unattended in the bathroom for approximately one hour despite using the call light for assistance. During this time, a CNA was reported to have been rude, throwing a shirt at R11 without providing the necessary help. This incident was not thoroughly investigated, and the grievance was not reported to the State Agency, indicating a failure in addressing the neglect and potential abuse. R18, who had severe cognitive impairment and required extensive assistance for daily activities, suffered a large bruise on her chest, likely from an improper transfer using a gait belt instead of the required Hoyer lift. The facility's records lacked documentation of an investigation into the origin of the bruising or the improper use of the gait belt. Observations revealed additional bruising on R18's body, and staff were unsure of how these injuries occurred. The facility did not report this incident to the State Agency, nor did it document any staff education on proper transfer techniques, highlighting a neglect in ensuring R18's safety and care. Both incidents demonstrate a failure to adhere to the facility's policies on preventing abuse and neglect, as well as a lack of proper investigation and reporting procedures. The facility's inaction placed both residents at risk for further neglect and abuse, as the necessary care and services were not provided, and the incidents were not adequately addressed or reported.
Failure to Report Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to report allegations of abuse, neglect, and mistreatment to the State Agency (SA) for two residents, R11 and R18, as required. R11, who had multiple medical conditions including cerebral infarction, COPD, and dementia, reported an incident where a Certified Nurse Aide (CNA) was rude and threw a shirt at her without providing assistance. Despite the grievance being documented, the facility did not conduct a thorough investigation or report the incident to the SA, leaving the resident at risk for ongoing mistreatment. R18, who had severe cognitive impairment and required extensive assistance for daily activities, was found with a large bruise on her chest, suspected to be caused by improper use of a gait belt during a transfer. The facility's records lacked documentation of an investigation into the origin of the bruising or the use of a gait belt on a resident who required a Hoyer lift. Despite the visible injuries, the facility did not report the incident to the SA, failing to identify it as a potential case of abuse or neglect. The facility's policies on abuse, neglect, and exploitation were not followed, as they did not implement proper procedures for investigating and reporting these incidents. The lack of investigation and reporting placed the residents at risk for further abuse and mistreatment, as the facility did not take the necessary steps to ensure their safety and dignity.
Failure to Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to fully investigate allegations of abuse, neglect, and injuries of unknown origin for two residents, R11 and R18, placing them at risk of ongoing mistreatment. R11, who had a history of multiple medical conditions including cerebral infarction, COPD, and dementia, reported an incident where a CNA was rude and threw a shirt at her without providing assistance. Despite the grievance being reported, the facility did not conduct a thorough investigation, as confirmed by Administrative Nurse D, who did not interview R11 or gather statements from staff present during the incident. R18, who had severe cognitive impairment and required extensive assistance for daily activities, was found with a large bruise on her chest, possibly from improper use of a gait belt during transfers. The facility's records lacked documentation of an investigation into the bruise's origin, and there was no evidence of staff education on proper transfer techniques. Observations revealed additional bruises on R18's body, yet the facility did not report these findings to the State Agency or complete a comprehensive investigation. The facility's policies on abuse, neglect, and exploitation were not followed, as they failed to investigate the allegations thoroughly and report them as required. This lack of action and documentation placed both residents at risk for further abuse and neglect, as the facility did not take adequate steps to ensure their safety and dignity.
Failure to Develop Comprehensive Care Plans for Residents with Indwelling Catheters
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents with indwelling urinary catheters, placing them at risk for impaired care due to uncommunicated care needs. Resident 55, who had multiple diagnoses including type two diabetes mellitus, heart failure, and dementia, was observed with a catheter drainage bag and tubing dragging on the floor, which was confirmed by a licensed nurse as inappropriate. The care plan for Resident 55 lacked interventions related to the indwelling catheter and psychotropic medication use, despite the resident's history of urinary tract infections and the administration of alprazolam for anxiety. Resident 17, with a history of urinary tract infections and other medical conditions such as chronic obstructive pulmonary disease and type two diabetes mellitus, was observed with a catheter drainage bag lying on the floor. The care plan for Resident 17 did not include directions for the indwelling catheter, even though the resident had been treated for multiple UTIs. A licensed nurse confirmed that the catheter bag should not be on the floor and that the resident's indwelling urinary catheter should have been care planned. Resident 20, diagnosed with cerebral palsy and neuromuscular dysfunction of the bladder, had a care plan that lacked interventions for the suprapubic catheter. Observations revealed that the catheter tubing was not properly anchored to prevent pulling or displacement. Administrative staff verified that the care plan should have included instructions for anchoring the catheter tubing. The facility's policy required comprehensive person-centered care plans, but these were not adequately developed for the residents involved.
Failure to Update Care Plan for Pressure Ulcer Interventions
Penalty
Summary
The facility failed to revise the care plan for a resident, identified as R19, to include necessary interventions for pressure ulcers. R19 had a history of cerebrovascular accident, hemiplegia, hemiparesis, dysphagia, and rheumatoid arthritis, and was dependent on staff for all activities of daily living. The resident had a Stage 4 pressure ulcer and required specific interventions such as a foot cradle to prevent further skin breakdown. Despite recommendations from an APRN on 11/27/23 to use a foot cradle, this intervention was not documented in the care plan until 01/24/24, leading to a delay in implementing the necessary care. Observations and interviews revealed that the facility's staff did not update the care plan in a timely manner, as required by the facility's policy. The care plan lacked documentation for the foot cradle, which was crucial for the resident's care. Administrative Nurse E acknowledged missing the recommendation for the foot cradle, and Administrative Nurse D confirmed that the care plan should have been updated immediately. This oversight placed the resident at risk for impaired care due to uncommunicated care needs.
Inconsistent Bathing for Resident with Dementia
Penalty
Summary
The facility failed to provide consistent bathing for Resident 38, who had a diagnosis of vascular dementia, PTSD, diabetes mellitus, and depressive disorder. The resident was independent with all activities of daily living except for bathing, for which he required partial to moderate assistance. The care plan for Resident 38, initiated in June 2021, directed staff to offer a choice of a whirlpool or shower based on his preference on chosen bath days and to notify the nurse if he refused. However, the facility's records showed that Resident 38 did not receive a bath or shower for extended periods in January and February 2024, with no documentation of refusal in the electronic medical record. Observations on February 28, 2024, revealed that Resident 38 wore a stocking cap and a red sweatshirt with multiple food stains, indicating a lack of proper hygiene. Interviews with staff confirmed that Resident 38 should have received his showers as requested and that there were no recorded refusals. The facility's policy on bathing residents, dated 2017, emphasized assisting residents with bathing to maintain hygiene and prevent skin issues. The failure to provide consistent bathing placed Resident 38 at risk for complications related to poor hygiene.
Deficiencies in Skin Care and Communication in LTC Facility
Penalty
Summary
The facility failed to provide care and treatment in accordance with professional standards for two residents with non-pressure related skin injuries. Resident 18, who had severely impaired cognition and required extensive assistance, developed a skin abrasion on her back due to staff leaving a Hoyer lift sling underneath her. This abrasion worsened over time, and despite physician orders for treatment, the area became irritated due to moisture and the resident's fragile skin. Observations revealed a large wet spot on the resident's clothing, and multiple bruises were noted on her body, indicating further issues with skin care and handling. Resident 17, who had intact cognition and required assistance with activities of daily living, reported pain in the right first toe extending to the ankle. The resident had a bandage on the toe, which was not documented in the clinical record, and staff were unaware of the issue. Upon assessment, the toe was found to have dried blood, redness, and drainage, indicating a need for medical attention. However, the facility failed to notify the physician about the condition, which was a requirement under their policy for changes in a resident's condition. The deficiencies in care for both residents highlight a lack of adherence to care plans and facility policies, resulting in inadequate treatment and monitoring of skin conditions. The failure to remove the Hoyer sling and the lack of communication regarding Resident 17's toe injury placed both residents at risk for further complications, including infection and impaired healing.
Inadequate Pressure Ulcer Care and Prevention for Two Residents
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for two residents, R11 and R19, who were either at risk for or had existing pressure injuries. R11, with a complex medical history including cerebral infarction, COPD, and rheumatoid arthritis, was identified as at risk for skin integrity issues due to decreased mobility. Despite having a care plan that included education on skin breakdown prevention and the use of specific cushions and mattresses, R11 did not receive a pressure-relieving cushion for her recliner. Additionally, R11's clinical record lacked evidence of nutritional supplements or dietician involvement, which are crucial for wound healing. Observations revealed that R11 had a painful sore on her buttock, and staff failed to provide necessary bandages, further exacerbating the situation. R19, who had a history of cerebrovascular accident, hemiplegia, and rheumatoid arthritis, was dependent on staff for all activities of daily living and had a Stage 4 pressure ulcer. The care plan for R19 included pressure relief interventions and nutritional support, but these were not implemented in a timely manner. The facility failed to follow through with the registered dietician's recommendation for Prostat and the APRN's recommendation for a foot cradle. Observations showed that R19's medication administration record lacked documentation for these interventions, and there was a delay in entering the order for Prostat into the facility system. The facility's policy on pressure ulcer prevention and management emphasized a systematic approach, including prompt assessment and treatment, and evidence-based interventions. However, the facility did not adhere to these guidelines, resulting in inadequate care for R11 and R19. The lack of timely and appropriate interventions placed both residents at risk for ongoing pressure injuries and related complications.
Failure to Provide ROM Services as Care Planned
Penalty
Summary
The facility failed to provide range of motion (ROM) services to Resident 19 as outlined in her care plan, which placed her at risk for impaired mobility and decreased function. Resident 19 had a history of cerebrovascular accident (CVA), hemiplegia, hemiparesis, dysphagia, and rheumatoid arthritis, and was dependent on staff for all activities of daily living (ADLs) and mobility. Her care plan required staff to provide gentle ROM exercises with morning and evening care daily. However, there was no documentation that these services were provided. Observations revealed that Resident 19 was often in positions that could lead to contractures, such as lying with clenched hands without padding or protection and sitting in a Broda chair while chewing on her thumbnail. Interviews with staff, including a Restorative Aide and a Certified Nurse Aide, confirmed that ROM services were not provided to Resident 19. The facility's policy on the prevention of decline in ROM required interventions to be documented and consistently implemented, which was not adhered to in this case.
Failure to Provide Adequate Nutritional Care
Penalty
Summary
The facility failed to provide necessary nutritional assessments and interventions for Resident 59, who had a history of weight loss prior to admission and continued to lose weight after being admitted. Despite being dependent on staff for all activities of daily living and having severely impaired cognition, the resident's care plan lacked documentation of diet orders and interventions to prevent weight loss. The facility did not notify the Registered Dietician (RD) or the physician about the resident's weight loss, and no nutritional assessments were completed. Observations revealed that the resident did not finish meals, and staff confirmed that no nutritional supplements were provided. Resident 19, who was on a pureed diet due to conditions such as cerebrovascular accident, hemiplegia, and dysphagia, did not receive the full nutritional benefit of the meals served. The care plan directed staff to monitor nutritional status and provide supplements as ordered, but during a meal observation, the resident did not receive all the components of the meal as listed on the menu. The RD had recommended specific supplements, but the resident received a different shake than requested, and the pureed stuffing was missing from the meal. The facility's policies on interventions for unintended weight loss and the responsibilities of the food and nutrition services department were not followed. The failure to implement immediate interventions and involve the RD and physician placed the residents at risk for further weight loss and decline. The facility's lack of adherence to its policies and procedures contributed to the deficiencies observed in the nutritional care of the residents.
Failure to Provide Mental Health Services
Penalty
Summary
The facility failed to provide appropriate mental health treatment and services to a resident, identified as R11, who had a history of mental health issues and expressed a need for mental health support. R11's electronic medical record indicated multiple diagnoses, including major depressive disorder and bipolar disorder, and the resident was on medications such as antidepressants and antianxiety drugs. Despite these conditions and the care plan's directives to monitor and report any mental health concerns, there was no evidence in R11's clinical record that mental health services were offered or provided at the facility. R11 reported feeling down and expressed a desire for mental health assistance, which she had not received since transitioning from another facility where she had been receiving such services. The resident, who was also the resident council president, mentioned that she stopped attending meals in the dining room due to another resident's behavior, which further isolated her. Social Service X confirmed that R11 had requested continued mental health services and that the previous provider had contacted the facility to ensure a smooth transition, but services had not yet commenced. Administrative Nurse D acknowledged that R11's participation in meals and activities had decreased and that she was more irritable with staff. The facility's Behavioral Health Services policy emphasized the importance of providing necessary behavioral health care to maintain residents' mental and psychosocial well-being. However, the facility did not adhere to this policy, resulting in R11 not receiving the mental health services she requested and needed, placing her at risk for unmet mental health care needs.
Failure to Monitor Blood Sugar Levels in Diabetic Resident
Penalty
Summary
The facility failed to ensure adequate monitoring of a resident's blood sugar levels, which is crucial for managing diabetes mellitus. The resident, who had a history of type 2 diabetes mellitus among other health conditions, was receiving insulin as part of their treatment. However, the care plan did not include parameters for notifying a physician in case of abnormal blood sugar levels. This oversight was evident when the resident's postprandial blood sugar level was recorded at 456 ml/dL, significantly higher than the normal range, without any documented physician notification or assessment. Additionally, the facility's medication regimen review process, which is supposed to identify and resolve medication-related problems, did not address the lack of blood sugar monitoring parameters. The administrative nurse was unable to confirm whether the physician had been notified about the high blood sugar reading, indicating a lapse in communication and protocol adherence. This deficiency placed the resident at risk of receiving unnecessary medications and potential complications related to their diabetes management.
Inadequate Infection Control in Catheter Care
Penalty
Summary
The facility failed to provide sanitary indwelling urinary catheter care according to standard infection prevention practices for three residents, identified as R17, R55, and R54. Observations revealed that R17's catheter drainage bag was improperly placed on the floor and not attached to the bed, despite the resident's history of urinary tract infections (UTIs). Similarly, R55's catheter drainage bag was observed resting on the floor mat next to the bed, and R54's catheter bag was placed on the floor during care. These actions were contrary to the facility's infection prevention protocols, which require catheter bags to be hung below the bladder level and never placed on the floor. Additionally, the facility's staff failed to adhere to proper hand hygiene and glove-changing protocols during catheter care. Certified Nurse Aide (CNA) N was observed placing a catheter bag on the floor, failing to change gloves or wash hands after providing care, and using the same gloves to assist a resident with clothing. CNA N also handled the catheter bag with ungloved hands and did not perform hand hygiene before entering another resident's room. These actions were inconsistent with the facility's Hand Hygiene Policy and Catheter Care Policy, which emphasize the importance of hand hygiene and changing gloves between clean and dirty tasks to prevent the spread of infection.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the citations issued around you in the last 12 months — including the 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 Beloit
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mitchell County Hospital Health Systems Ltcu | 0.1 mi | ★★★★★ | 0 | 0 |
| The Nicol Home | 16.5 mi | ★★★★★ | 0 | 0 |
| Downs Care And Rehab | 23.3 mi | ★★★★★ | 0 | 0 |
| Sunset Home Inc | 24.7 mi | ★★★★★ | 0 | 0 |
| Lincoln Park Manor Inc | 28.9 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.