Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hilltop Estates during CMS and state inspections, most recent first.
Failure to follow posted menus, recipes, and portion controls led to meal preparation that did not match the planned menu. A DM substituted dinner rolls for egg rolls without RD approval, brownies were prepared inconsistently with the recipe, and the cook used unmeasured ingredients for the noodles and reduced amounts of beef, broccoli, onions, and water in the stir-fry. During service, portions were inconsistent, and the Admin confirmed residents did not receive the required protein and appropriate portions.
The facility failed to follow hand hygiene and food safety practices during meal prep and service. A cook handled food with gloves and bare hands without performing hand hygiene after removing gloves, and also prepared sandwiches and plates for residents without washing hands between tasks. In addition, refrigerator and freezer temp logs were missing entries, and hot food was served when a beef and broccoli dish measured 105 degrees F while noodles were not checked; the DON confirmed hot foods should remain above 135 degrees F.
Failure to Obtain Psychotropic Medication Consent Before Initiation or Dose Increase: The DON confirmed that consent forms for psychotropic meds were missing from the records for three sampled residents, and the forms were not completed before the meds were started or increased. One resident was cognitively intact with depression and was receiving an antipsychotic and an antidepressant; another had severe cognitive impairment, dementia, agitation, and was receiving an antipsychotic and lorazepam; the third was cognitively intact with depression, PTSD, and was receiving an antidepressant and an antipsychotic. The facility later obtained telephone consent from POAs, but the required consent documentation was not in place before treatment began.
Failure to Complete Significant Change MDS Assessments: The facility failed to complete SCSA MDS assessments for two residents after significant declines in condition. One resident had worsening cognition, mood changes, increased dependence for ADLs, new incontinence, a stage 2 pressure injury, a surgical wound, and IV abx after readmission with osteomyelitis and an abscess. Another resident returned after hip fracture repair and later showed new rejection behavior, greater dependence for bed mobility, toileting, and transfers, limited ROM, and new bowel and bladder incontinence. In both cases, the MDSC confirmed the changes met the definition of a significant change, but routine MDS assessments were completed instead.
The facility failed to accurately code MDS assessments for two residents. One resident received daily Aspirin, an antiplatelet, during the look-back periods for both a quarterly and annual MDS, but section N0415 item I was not coded to show antiplatelet use. Another resident had documented nightly BiPAP use on the TAR, but section O0110 item G2 on the comprehensive MDS was not coded to reflect BiPAP use. The MDSC confirmed both assessments were coded incorrectly.
A facility failed to complete glucometer QC testing when new test strip bottles were opened for two residents, and staff confirmed the required control solution entries were missing from the log. The facility also failed to follow PICC dressing-change technique for a resident, with the RN using nonsterile handling steps and contaminating concerns during the procedure. In addition, the RN did not flush both PICC lumens as ordered and the resident’s MAR order for IV Unasyn lacked key administration details such as the infusion amount, duration, and rate.
Improper Disposal of Unused Medication: An LPN prepared Questran powder for a resident, but when the resident declined to take it at that time, the LPN poured the dissolved medication into the toilet and flushed it. Facility policy prohibited flushing prescription drugs and required destruction to be witnessed by two approved staff members and recorded before placement in a medication disposal bottle; the LPN and DON both confirmed the disposal was done incorrectly.
Improper Disposal of Blood-Contaminated Waste: An LPN discarded a blood-containing glucose test strip and cotton ball into a resident’s trash can after a finger-stick blood sugar check, despite facility policy and device instructions identifying the items as biohazard waste. In a separate event, an RN discarded a syringe containing visible blood after PICC line care into another resident’s trash can; the RN and DON confirmed contaminated waste should not be placed in residents’ trash cans.
The facility failed to maintain safe temperatures in both the walk-through refrigerator and the high temperature dishwasher. The refrigerator consistently exceeded the safe temperature of 41°F, with milk stored at unsafe levels. The dishwasher failed to reach the required minimum rinse temperature of 180°F, with cycles maxing out at 140°F. These deficiencies had the potential to affect all residents consuming food from the facility's kitchen.
A facility failed to follow infection control protocols by not cleansing an insulin pen tip and not disinfecting a glucometer after use for a resident. Additionally, employee health screenings were incomplete for two staff members, as required documentation was either missing or not reviewed.
A resident with depression and cognitive impairment was not properly monitored for changes in mood or adverse effects from psychotropic medication, as required by their care plan. Despite noticeable declines in activity participation and meal attendance, these changes were not reported by staff to nursing or social services, resulting in a deficiency in providing necessary behavioral health care.
The facility exceeded the acceptable medication error rate, reaching 12% instead of the required 5% or less. An LPN administered incorrect dosages to two residents, including extra tablets and unauthorized medications. The errors were confirmed by the LPN and the DON.
The facility failed to maintain the required high temperature for sanitization in the dishwashing machine, affecting all 43 residents. Observations and manual checks revealed temperatures significantly below the required 180 degrees Fahrenheit, and the Dietary Cook was unfamiliar with the monitoring process.
The facility failed to follow transmission-based precautions during a COVID-19 outbreak, with staff not changing or cleaning N95 masks and goggles after exiting isolation rooms. This non-compliance with infection control guidelines had the potential to affect all 43 residents.
The facility did not provide the required Advanced Beneficiary Notice of Non-Coverage and the Notice of Medicare Non-Coverage to a resident at least two days prior to the end of Medicare Part A services. The notices were dated after the last covered day, and the Business Office Manager confirmed the delay.
Failure to Follow Menus, Recipes, and Portion Controls
Penalty
Summary
The facility failed to follow the posted menu, recipes, and portion controls for the noon meal, affecting all residents eating from the kitchen. The posted menu called for beef and broccoli stir fry with fettuccine noodles, buttered bread roll, soft brownies, and a beverage, and the facility policy stated meals should be nourishing, palatable, attractive, and meet residents’ daily nutritional needs. The Dietary Manager confirmed that buttered dinner rolls were substituted for the egg rolls because the ordered egg rolls were not liked, and the Administrator confirmed that this substitution had not been approved by the Registered Dietitian. The brownie dessert was also prepared inconsistently with the recipe. The recipe called only for brownie mix and water, but observation showed brownies that resembled a dump cake with dry ingredients on top. The cook stated too much butter had been used and more cake mix was sprinkled on top of the dessert. This resulted in a dessert that did not match the recipe that had been provided. The stir-fried noodles and beef and broccoli stir-fry were also not prepared according to the recipes. The noodle recipe required measured amounts of pasta, water, oil, green onion, pepper, and soy sauce, but the cook used four 16-ounce boxes of fettuccine, an unmeasured amount of hot water, and an unmeasured amount of vegetable oil, then held the noodles in a hotbox. The beef and broccoli recipe required 12 pounds of beef, 10 pounds of broccoli, 7 onions, and 1 quart and 2 cups of water for 48 servings, but the cook used only 10 pounds of beef, 6 pounds of broccoli, 2 onions, and no water, resulting in a very sticky consistency. During service, the cook used inconsistent portions of noodles and meat and vegetable mixture when plating 32 meals, and the Administrator confirmed residents did not receive the required amount of protein and that the portions were not appropriate.
Food Safety and Hand Hygiene Failures During Meal Service
Penalty
Summary
The facility failed to perform hand hygiene when working with food during meal preparation and service. Record review of the facility’s hand hygiene policy stated that staff are to perform proper hand hygiene and that gloves do not replace hand hygiene. During observation, the cook wore gloves while handling meat and broccoli, removed the gloves, and continued working without performing hand hygiene. During noon meal service, the cook washed hands before starting, then repeatedly handled prepared food and meal plates with gloved or bare hands without hand hygiene after removing gloves, including preparing sandwiches and hamburger plates for residents and handing food to the dietary aide through the service window. The cook confirmed not washing hands after donning and doffing gloves, and the dietary manager confirmed hand hygiene must be followed during meal service and food preparation. The facility also failed to consistently monitor temperatures of the walk-in refrigerator and freezer. Record review of the HACCP and food safety policy stated staff would be trained on food safety procedures and that supervisors would monitor staff. Review of the dietary staff meeting notes showed cooks were told to start taking temperatures and charting them, including before serving. However, the walk-in freezer temperature logs for June 2026 were missing entries for 6/6/26, 6/7/26, and the morning of 6/9/26, and the walk-in refrigerator logs were also missing entries for those same times. The dietary manager confirmed the missing temperature recordings during interview. The facility further failed to maintain and verify hot food temperatures during meal service. During observation of the noon meal, the cook checked the beef and broccoli and found it at 105 degrees Fahrenheit, but did not check the noodles. The food was then handed to the dietary aide for delivery to the table, and the cook confirmed the meal was served without rewarming. Later, the remaining food on the steam table was checked and was above 135 degrees Fahrenheit. The dietary manager confirmed that hot foods are to always be above 135 degrees Fahrenheit during meal service.
Failure to Obtain Psychotropic Medication Consent Before Initiation or Dose Increase
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were fully informed of the risks and benefits of psychotropic medications before the first dose was given or when the dosage was increased. The deficiency involved 3 of 5 sampled residents: Resident 2, Resident 21, and Resident 26. The facility policy stated that prior to initiating or increasing a psychotropic medication, the resident, family, and/or resident representative must be informed of the benefits, risks, alternatives, and any black box warnings for antipsychotic medications in advance of the initiation or increase. During record review and interview, the DON confirmed that no Consent for the Use of Psychotropic Medications forms were found in the records for Residents 2, 21, and 26 during chart audits prior to the survey. The DON stated that nursing staff did call families to notify them of medication changes, but the forms had not been completed prior to 6.3.26. The DON further confirmed that when the missing documents were discovered, the facility contacted the POAs for these residents and received telephone consents. Resident 21 had a BIMS score of 15, no rejection of care, no wandering, and no behaviors in the 7-day look-back period, with diagnoses including non-Alzheimer's dementia, depression, and major depressive disorder. This resident had orders for Abilify 5 mg 1/2 tablet at bedtime for depression and bupropion hydrochloride 150 mg at bedtime for major depressive disorder. Resident 26 had severe cognitive impairment, was rarely understood, had rejection of care and treatments 1 to 3 times a week, and diagnoses including progressive neurological disorder, non-Alzheimer's dementia, severe malnutrition, restlessness, and agitation. This resident had orders for risperidone 0.5 mg twice a day for dementia with agitation and lorazepam for restlessness and agitation. Resident 2 had a BIMS score of 15, no hallucinations, delusions, behaviors, psychosis, refusal of care, or wandering, and diagnoses including non-Alzheimer's dementia, depression, PTSD, and major depressive disorder. This resident had orders for citalopram 40 mg daily for major depressive disorder and Abilify 10 mg at bedtime for PTSD. In each case, the consent forms were completed after the medications had already been started, and one medication listed for Resident 26 had already been discontinued before the consent date.
Failure to Complete Significant Change MDS Assessments
Penalty
Summary
The facility failed to complete a Significant Change Minimum Data Set (MDS) assessment within 14 days of identifying a significant status change for 2 of 12 sampled residents. The cited requirement stated that a Significant Change Assessment (SCSA) is to be completed when a resident has a decline or improvement in status that is not self-limiting, affects more than one area of health status, and requires interdisciplinary review or care plan revision. The facility policy also stated that a Significant Change Assessment should be completed within 14 days of the identification of a status change. For Resident 6, the record showed the resident was readmitted with osteomyelitis of the right thigh, an abscess of the right lower limb, and pressure-induced deep tissue damage of the sacral region. The prior Quarterly MDS showed a BIMS score of 10, no mood alterations, use of a walker and wheelchair, set up or clean up assistance with eating, partial to moderate assistance with bed mobility, toilet use, and transfers, continence of bowel and bladder, and no unhealed pressure-related skin alterations. The later Annual MDS showed a BIMS score of 6, mood alteration of little pleasure and interest in doing things, wheelchair use only, increased assistance needs for eating, bed mobility, toilet use, and transfers, frequent bowel and bladder incontinence, a stage 2 pressure-related skin alteration, a surgical wound, and routine IV antibiotic medication. The MDS Coordinator confirmed the resident had a change or decline in condition and that the changes met the definition of a significant change in status, but an Annual assessment was completed instead of an SCSA. For Resident 43, the record showed the resident was readmitted from a hospital leave following surgical repair of a hip fracture. The admission MDS showed no behavior coding, moderate assistance with bed mobility, toilet use, and transfers, continence of bowel and bladder, and no limitations in functional range of motion. The later Quarterly MDS showed rejection behavior, substantial or maximal assistance with bed mobility, dependence for toilet use and transfers, limitation in functional range of motion to one lower extremity, and occasional bowel and bladder incontinence. The MDS Coordinator confirmed the resident had a change or decline in condition and that the changes met the definition of a significant change in status, but a Quarterly assessment was completed instead of an SCSA.
MDS Coding Errors for Antiplatelet Use and BiPAP
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for two residents. For Resident 6, the Medication Administration Record showed daily administration of Aspirin 81 mg, an antiplatelet medication, during the 7-day look-back periods for both the Quarterly MDS with an ARD of 02/24/2026 and the Annual MDS with an ARD of 05/11/2026. However, section N0415 item I on both assessments was not coded to reflect that the resident received an antiplatelet medication during those periods. For Resident 43, the Treatment Administration Record showed that the resident used BiPAP at night during the look-back period for the comprehensive MDS with an ARD of 04/06/2026, with staff documenting verification of use every bedtime. Despite this documentation, section O0110 item G2 on the MDS was not coded to indicate BiPAP use during the look-back period. During interview, the MDS Coordinator confirmed that both residents' MDS assessments were not coded correctly.
Missed Glucometer QC, PICC Care, and IV Order Deficiencies
Penalty
Summary
The facility failed to complete glucometer control testing when new bottles of test strips were opened for two residents. For one resident, the bottle of test strips in the medication cart was labeled with an open date of 06/10/2026, but the Glucometer Calibration and Quality Control Log did not contain a corresponding entry for that date. For another resident, the bottle of test strips was labeled with an open date of 06/13/2026, but the log only showed an earlier entry from 02/21/2026 and no entry for the new bottle. Staff interviews confirmed that control solution testing was to be completed and recorded when each new test strip bottle was opened, and the Director of Nursing confirmed the log was not completed for either resident. The facility also failed to provide PICC line care according to its policy for one resident. During a dressing change, the RN opened the sterile dressing kit using a fanning motion, placed the resident’s arm on the sterile drape near other sterile items, did not remove gloves and perform hand hygiene before continuing, and then applied sterile gloves. The RN also measured the resident’s arm and catheter after the site had already been cleansed, allowed the measuring tape to touch uncleansed skin, and then used the same tape to measure the catheter. The RN acknowledged these actions did not follow the facility policy and confirmed the dressing change was not completed in a manner that prevented cross contamination. The facility further failed to follow provider orders for flushing the resident’s PICC line and failed to ensure the IV medication order contained complete administration instructions. The resident had an order to flush both lumens four times daily, but during observation the RN flushed only the lumen being used for the IV infusion and did not flush both lumens as ordered. The resident’s MAR order for Unasyn also did not include the amount of solution to be infused, the length of time the medication was to be infused over, or the rate of infusion. The IV bag label, however, stated that Unasyn 3 grams in normal saline 100 milliliters was to infuse over 30 minutes at 200 milliliters per hour every 6 hours, and the RN confirmed the MAR order did not match the pharmacy label and lacked those required details.
Improper Disposal of Unused Medication
Penalty
Summary
The facility failed to dispose and/or destroy a medication in compliance with applicable state and federal requirements for one resident. During an observed medication administration, an LPN emptied a packet of Questran Powder 4 gm into approximately 4 ounces of water and stirred it. The LPN brought the dissolved medication and the resident’s pills into the resident’s room, where the resident stated they did not want to take the powder medication until after breakfast, around 9:00 AM, because they preferred to take it after their meal and other medications. After the resident declined the medication at that time, the LPN took the cup containing the dissolved Questran into the resident’s bathroom and poured it into the toilet, then flushed it. The facility policy stated that prescription drugs may not be flushed down the toilet and that drug destruction was to be witnessed by two approved staff members, recorded on the medication destruction record, and placed into a drug disposal bottle. The LPN later confirmed the medication was not disposed of correctly, and the DON also confirmed that the medication should not have been flushed down the toilet.
Improper Disposal of Blood-Contaminated Waste
Penalty
Summary
The facility failed to dispose of regulated waste in a manner consistent with manufacturer and facility policy for two residents. During a blood glucose check for Resident 21, an LPN used a retractable lancet to obtain a finger-stick blood sample, wiped away visible blood with a cotton ball, and then used an Assure Platinum blood glucose test strip to obtain the reading. After the test, the LPN removed the blood-containing test strip and threw it, along with the blood-soaked cotton ball, into the resident’s trash can beside the bed. Facility policy defined regulated waste as pathological and microbiological wastes containing blood or other potentially infectious materials and required use of single, leak-resistant biohazard bags, and the blood glucose monitoring system instructions stated that all components that contact blood should be considered biohazards. The LPN confirmed the items were potentially contaminated and should have been disposed of per facility policy. During IV medication preparation for Resident 6, an RN cleansed the catheter end of the resident’s double lumen PICC line, attached a syringe containing 10 milliliters of sodium chloride, and flushed the line. The RN left the empty syringe attached to the PICC line while preparing the IV solution, then returned and removed the syringe, which contained visible red liquid substance approximately one-quarter full. The RN threw the syringe containing the red liquid into the resident’s trash can on the floor beside the bed and then completed the IV medication procedure. The RN later confirmed the syringe contained blood and should not have been discarded in the resident’s trash can, and the DON confirmed that contaminated waste should not be disposed of in residents’ trash cans.
Temperature Control Failures in Refrigerator and Dishwasher
Penalty
Summary
The facility failed to maintain safe temperatures in the walk-through refrigerator, as observed on multiple occasions. Temperature logs indicated that the refrigerator exceeded the safe temperature of 41 degrees Fahrenheit on several dates, with readings of 42, 42, and 45 degrees Fahrenheit. On the day of observation, the refrigerator's temperature was recorded at 44 degrees Fahrenheit, and further checks revealed a temperature of 46 degrees Fahrenheit. Milk stored in the refrigerator was found to be at unsafe temperatures, with an opened gallon reaching 56 degrees Fahrenheit and an unopened gallon at 46 degrees Fahrenheit. The Dietary Manager acknowledged the unsafe temperature readings and the Administrator confirmed the refrigerator was not maintaining safe temperatures for food storage. Additionally, the facility's high temperature dishwasher failed to reach the required minimum rinse temperature of 180 degrees Fahrenheit. Observations showed the dishwasher's temperature maxed out at 140 degrees Fahrenheit across various cycles. The Dishwasher Temperature Log had missing entries, and staff were uncertain about the correct temperature readings. The Administrator observed the dishwasher's cycle and confirmed it was not maintaining safe temperatures, instructing the kitchen staff to cease using the dishwasher until it was repaired. These deficiencies had the potential to affect all residents consuming food from the facility's kitchen.
Infection Control and Employee Health Screening Deficiencies
Penalty
Summary
The facility failed to adhere to its infection prevention and control protocols, as evidenced by the improper handling of an insulin pen and glucometer. During an observation, a Medication Aide (MA) did not cleanse the tip of an insulin pen with an alcohol wipe before attaching the needle cap and administering insulin to a resident. This action was contrary to the facility's policy, which requires the rubber seal of the insulin pen to be wiped with an alcohol pad before use. Both the MA and the Director of Nursing (DON) confirmed that the insulin pen tip should have been cleansed prior to use. Additionally, the same MA failed to disinfect a glucometer after using it to check the resident's blood sugar. The glucometer was placed back into a drawer and returned to the medication cart without being cleaned with disinfectant wipes, as required by the facility's policy. The MA and the DON acknowledged that the glucometer should have been disinfected after use. Furthermore, the facility did not complete and review employee health screenings for two of the five sampled staff members, as evidenced by incomplete or missing Employee Health Checklists in their files.
Failure to Monitor Resident's Psychosocial Well-being and Medication Effects
Penalty
Summary
The facility failed to observe and monitor a resident, identified as Resident 41, for changes in their psychosocial or mood state and for adverse effects from their psychotropic medication, as per the resident's care plan. Resident 41 was admitted with diagnoses including polyosteoarthritis, macular degeneration, and depression, and was moderately cognitively impaired with mild depression. The resident's care plan included goals and approaches to address psychosocial well-being and psychotropic drug use, but these were not adequately followed. Interviews and record reviews revealed that Resident 41 experienced a decline in participation in activities and meals, which was not reported to the appropriate staff. The Activity Director noted a decrease in the resident's activity participation but did not communicate this change to nursing or social services. Similarly, a Medication Aide observed the resident's refusal to attend meals but failed to report it. The Social Service Director and Registered Nurse confirmed they were unaware of these changes, indicating a lack of monitoring and communication among staff. The Director of Nursing acknowledged that Resident 41 was not being monitored for mood or behavior changes, which was a requirement of the resident's care plan. This oversight resulted in the facility's failure to provide necessary behavioral health care and services, as mandated by their policy and the resident's care plan, leading to the identified deficiency.
Medication Error Rate Exceeds Acceptable Limit
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less, resulting in an actual medication error rate of 12%. This deficiency affected two residents out of a sample of four, with a facility census of 44. The errors were identified during observations of medication administration by an LPN. For Resident 9, the LPN administered two Senna Plus tablets instead of the prescribed one and also gave a Calcium with Vitamin D tablet, which was not ordered for the resident. The LPN confirmed these were medication errors during an interview. For Resident 37, the LPN administered two Acetaminophen 500 MG tablets instead of the prescribed one tablet. This was also confirmed as a medication error by the LPN. The Director of Nursing corroborated these errors during interviews, acknowledging the discrepancies between the prescribed orders and the medications administered to the residents.
Failure to Maintain Required Dishwasher Sanitization Temperature
Penalty
Summary
The facility failed to ensure that the high temperature dishwashing machine maintained the required high temperature for sanitization of facility dishware. During an observation, the final rinse cycle of the dishwashing machine was found to be reaching only 142 degrees Fahrenheit, significantly below the required 180 degrees Fahrenheit. A manual temperature gauge confirmed a final rinse temperature of 147.5 degrees Fahrenheit. The Dietary Cook was unfamiliar with the process of monitoring the temperature, indicating a lack of proper training or adherence to the facility's policy on dishwasher temperatures. Record reviews revealed that the Dishwasher Temperature Chart for the month of March 2024 listed temperatures within the required range, but the section for corrective actions was left blank, suggesting that no corrective measures were taken when temperatures fell below the required levels. Interviews with the Dietary Manager confirmed that the facility uses a high temperature sanitization dishwasher and provided the temperature logs and policy. However, the failure to maintain the required sanitization temperature affected all 43 residents who receive meals from the facility kitchen.
Failure to Follow Transmission-Based Precautions During COVID-19 Outbreak
Penalty
Summary
The facility failed to follow transmission-based precautions to prevent the spread of communicable diseases during a COVID-19 outbreak. Observations revealed that rooms designated as Red Zone Isolation areas lacked essential PPE such as surgical masks, N95 masks, alcohol-based hand gel, goggles, face shields, and sanitizing wipes. Interviews with staff, including a housekeeper and a medication aide, indicated that N95 masks and goggles were worn for the entire shift without being changed or cleaned after exiting isolation rooms. The Director of Nursing (DON) and Infection Preventionist (IP) confirmed these practices, stating that the facility was following extended use guidelines for PPE, which were not in line with conventional standards for infection control. A review of facility policies and communications from the Infection Control Assessment and Promotion Program (ICAP) revealed that extended use of N95 masks and goggles should only be employed as a contingency strategy during PPE shortages. The facility's policy required that N95 masks and face shields be discarded after each resident care encounter, and reusable eye protection should be cleaned whenever removed. The facility's failure to adhere to these guidelines and policies had the potential to affect all 43 residents in the facility, as confirmed by the facility's census and the observations made during the survey.
Failure to Provide Timely Medicare Coverage Notices
Penalty
Summary
The facility failed to provide the required Advanced Beneficiary Notice of Non-Coverage and the Notice of Medicare Non-Coverage to Resident 29 at least two days prior to the end of Medicare Part A services. Record reviews revealed that the notices were dated 3/18/2024, while the last covered day of services was 3/15/2024, indicating that the resident or their representative was not notified in advance as required. An observation on 03/20/24 confirmed that Resident 29 was in their room, and an interview with the Business Office Manager corroborated that the notice was not given prior to the end of services on 3/15/24.
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What surveyors actually found near you
We read the 1 citations issued within 25 miles in the last 12 months — 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
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Nursing homes near Gothenburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Emerald Nursing & Rehab Cozad | 9.9 mi | ★★★★★ | 1 | 0 |
| Callaway Good Life Center, Inc | 26.6 mi | ★★★★★ | 15 | 0 |
| Elwood Care Center | 28.9 mi | ★★★★★ | 8 | 0 |
| Adept Nursing & Rehab Of North Platte | 34.5 mi | ★★★★★ | 4 | 0 |
| Accura Healthcare Of North Platte | 36.2 mi | ★★★★★ | 12 | 0 |
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