Below average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Hill Top Home Of Comfort Inc during CMS and state inspections, most recent first.
Failure to change oxygen tubing per physician order. A resident who used O2 via nasal cannula had orders for weekly tubing changes and filter cleaning, and the care plan addressed maintaining O2 saturations above 90%. Surveyors observed the resident wearing tubing labeled with an older date, while the TAR showed staff documented the tubing had been changed, indicating the ordered tubing change schedule was not followed.
A facility failed to prevent resident-to-resident abuse involving three residents. Two residents were found in a compromising situation, which was not identified as sexual abuse by staff. Another resident led a female resident into his room and barricaded the door, an act not recognized as physical abuse. The facility's policy on abuse was not effectively implemented, and care plans did not address residents' needs regarding physical contact.
The facility failed to report potential abuse incidents involving residents with cognitive impairments to the SSA, leading to a deficiency. Incidents included inappropriate physical interactions and aggressive behavior, which were not reported as required by policy. This placed residents at risk for potential abuse and injury.
The facility failed to investigate incidents of resident-to-resident abuse involving three residents, leading to an Immediate Jeopardy situation. Incidents included inappropriate physical contact and aggression, with no investigations conducted to determine the extent of abuse or protect the residents involved.
The facility failed to accurately code the MDS for two residents, missing documentation of a hypoglycemic medication and continuous oxygen therapy. An administrative nurse confirmed these omissions during the survey, indicating a lapse in maintaining accurate resident assessments.
The facility failed to update care plans for two residents, impacting staff's ability to provide appropriate care. One resident with Alzheimer's and dementia exhibited aggressive behaviors, but the care plan did not address these issues. Another resident with COPD required continuous oxygen, but the care plan was not updated to reflect this need or the resident's refusal to wear the nasal cannula. An administrative staff member confirmed these oversights.
Failure to Change Oxygen Tubing per Order
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed. The facility failed to ensure that Resident #29 received respiratory care and services in accordance with professional standards of practice. Resident #29 had physician’s orders dated 11/18/23 to change oxygen tubing weekly and wash the concentrator filter at night once a day on Friday, and the care plan identified oxygen use with a goal to keep oxygen saturations above 90%. On all days of the survey, Resident #29 was observed wearing oxygen via nasal cannula with tape on the tubing labeled 08/15/25. The Treatment Administration Record showed staff signed on 08/22/25 indicating the oxygen tubing had been changed, but the date on the tubing remained 08/15/25. The facility failed to ensure staff changed the oxygen tubing according to the physician’s orders.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from abuse, specifically resident-to-resident abuse, involving three residents. Resident #34 and Resident #210 were found in a compromising situation where they were engaged in kissing and touching, with Resident #34 partially undressed. This incident was not identified as sexual abuse by the administrative nurses, despite the potential for mental and emotional distress. Resident #34 had a history of trauma and was diagnosed with dementia, anxiety, and post-traumatic stress disorder, while Resident #210 had severely impaired cognition and a history of sexually inappropriate behavior. Another incident involved Resident #48, who led Resident #34 into his room and barricaded the door with a chair. Despite attempts to intervene, Resident #48 became aggressive and refused to allow Resident #34 to leave the room. This behavior was not recognized as physical abuse by the administrative staff. Resident #48 had a history of dementia, Alzheimer's disease, and anxiety, with moderately impaired cognition. The facility's policy on abuse, neglect, and exploitation was not effectively implemented, as evidenced by the failure to identify and address these incidents as abuse. The care plans for the involved residents did not adequately address their wishes or needs regarding physical contact with other residents, contributing to the deficiency. The lack of a system to assess and care plan for residents' needs and behaviors led to these incidents of abuse.
Failure to Report Abuse Incidents
Penalty
Summary
The facility failed to report potential abuse incidents involving three residents to the State Survey Agency (SSA), which led to a deficiency being identified during a recertification survey. The incidents involved residents with cognitive impairments, including dementia and Alzheimer's disease, engaging in inappropriate physical interactions. These interactions were not reported to the SSA as required by the facility's policy, which mandates reporting of all alleged violations within specified timeframes. One incident involved two residents, one of whom was found undressed and engaged in physical contact with another resident in a room. Despite the situation being addressed by staff, there was no evidence that this incident was reported to the SSA. Another incident involved a resident leading another into his room, barricading the door, and becoming aggressive when staff attempted to intervene. This incident also lacked documentation of being reported to the SSA. The failure to report these incidents placed residents at risk for potential abuse and injury. The facility's policy on abuse, neglect, and exploitation requires timely reporting of such incidents to the appropriate authorities, including the SSA, but this was not adhered to in these cases. Interviews with administrative staff confirmed the lack of reporting, which contributed to the identification of an Immediate Jeopardy situation by the survey team.
Failure to Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to investigate incidents of resident-to-resident abuse involving three residents, which led to an Immediate Jeopardy (IJ) situation. The incidents involved inappropriate physical and sexual contact between residents, including one instance where a resident was found undressed and engaged in physical contact with another resident. The facility did not initiate or complete investigations into these incidents, which were documented in the residents' medical records. Resident #34, who has dementia and moderately impaired cognition, was involved in an incident with Resident #210, who also has dementia and severely impaired cognition. They were found in a compromising situation, with Resident #34 undressed and both residents engaged in kissing and touching. Despite the documentation of this incident in the medical records, the facility did not conduct an investigation to determine the extent of the abuse or to protect the residents involved. Another incident involved Resident #48, who has dementia, Alzheimer's disease, and anxiety, leading a female resident into his room and barricading the door. This resident became aggressive and refused to allow the female resident to leave, resulting in a physical altercation when staff intervened. Again, the facility failed to investigate this incident, leaving the residents at risk for further harm.
Inaccurate MDS Documentation for Medications and Treatments
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for two residents, which is crucial for reflecting their current status and needs. For one resident, the medical record indicated a physician's order for Metformin, a hypoglycemic medication, which was not documented in the MDS. This oversight was confirmed by an administrative nurse during the survey. The failure to document the use of hypoglycemic medication on the MDS could lead to an inaccurate assessment of the resident's needs. Another resident's medical record showed continuous oxygen therapy was administered daily over a specified period. However, this treatment was not recorded in the MDS, as confirmed by the same administrative nurse. The lack of documentation of continuous oxygen use on the MDS could result in an incomplete assessment of the resident's medical requirements. These inaccuracies in the MDS documentation were identified during the survey, highlighting the facility's failure to maintain accurate resident assessments.
Failure to Update Care Plans for Behavioral and Oxygen Needs
Penalty
Summary
The facility failed to review and revise care plans for two residents, which limited staff's ability to communicate needs and ensure continuity of care. Resident #48, diagnosed with Alzheimer's disease, anxiety disorder, delusional disorders, and dementia with psychotic disturbance, exhibited verbal and physical behaviors on multiple occasions from October 2023 to May 2024. Despite these incidents, the care plan for Resident #48 did not address behavioral symptoms related to verbal and physical aggression towards others, focusing instead on the risk of elopement and wandering. Resident #56, diagnosed with chronic obstructive pulmonary disease (COPD) and wheezing, had a physician's order for continuous oxygen use to maintain oxygen saturation above 90%. However, the care plan was not updated to reflect the need for continuous oxygen use, nor did it address the resident's occasional refusal to wear the nasal cannula. An administrative staff member confirmed the oversight in updating Resident #56's care plan regarding oxygen use.
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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.
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Nursing homes near Killdeer
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St Lukes Home | 33 mi | ★★★★★ | 0 | 0 |
| St Benedicts Health Center | 33.2 mi | ★★★★★ | 1 | 0 |
| Mckenzie County Healthcare Systems Long Term Care | 38.4 mi | ★★★★★ | 0 | 0 |
| Richardton Health Center Inc | 39.3 mi | ★★★★★ | 3 | 0 |
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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.