Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hilltop Estates during CMS and state inspections, most recent first.
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.
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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Illustrative
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 | ★★★★★ | 0 | 0 |
| Adept Nursing & Rehab Of North Platte | 34.5 mi | ★★★★★ | 4 | 0 |
| Accura Healthcare Of North Platte | 36.2 mi | ★★★★★ | 0 | 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.