Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 The Hilltop On Main during CMS and state inspections, most recent first.
No 24-hour licensed nurse coverage was provided on multiple days, according to PBJ staffing data. Interviews with an LVN, another LVN, the MD, the DON, and the ADM showed differing awareness of the staffing gaps, while the facility policy required licensed nurses and CNAs to be available 24/7 and a licensed nurse to serve as charge nurse on each shift.
The facility failed to maintain RN coverage for at least 8 consecutive hours each day and failed to keep a full-time DON in place. Records showed long gaps without a DON and multiple dates without RN coverage, with no RN coverage continuing into early 2026. Staff and the MD described ongoing shortages, frequent turnover of DONs, and reliance on sister facilities for supervisory guidance when RN or DON coverage was absent.
Failure to Assess and Obtain Consent Before Bed Rail Use: The facility used bed rails for several residents without documenting the required risk assessment, review of risks and benefits, or informed consent. Records and observations showed bed rails attached to beds for multiple residents, including residents with diagnoses such as stroke, COPD, morbid obesity, amputations, diabetes with neuropathy, and muscle weakness, while chart review did not show the required assessment, order, care plan documentation, or consent for bed rail, grab bar, or side rail use.
Failure to post daily nurse staffing information. The facility did not have the required staffing postings available for review, and an LVN searched the nursing station, surrounding area, and folders without finding any daily postings. The DON stated she was new to the facility and was not aware it was her duty to post the information, while the facility policy stated direct care daily staffing numbers are posted for every shift.
Inaccurate MDS Did Not Reflect Insulin and Injection Use: A resident with dementia and diabetes had an MDS that failed to show insulin and other injections that were actually given, even though the MAR and orders confirmed the treatments were administered. The MDS assessor acknowledged the omission as an oversight, and the LVN and ADM stated that MDS assessments must accurately reflect residents’ needs and treatment use.
A CNA failed to use appropriate communication and redirection with two residents during lunch service. One resident with dementia and severe cognitive impairment repeatedly asked for the TV to be turned on, but the CNA responded in a belittling tone, refused the request, and took the remote away. The interaction escalated when another resident became involved, pointed at the resident, and threatened him. Staff later stated the CNA escalated the situation and did not use appropriate de-escalation or resident-centered communication.
Surveyors found that food items in the kitchen's freezer, cooler, and refrigerator were not labeled with product names or use-by dates, and some were improperly sealed. The industrial can opener was observed to have a black sticky residue, indicating it was not properly cleaned. Additionally, the dishwasher's sanitizer concentration was below the required level, as confirmed by a failed test strip. Staff interviews confirmed that these practices did not meet facility policy or professional standards.
A DON failed to don a gown while administering a gastrostomy feeding to a resident with severe cognitive impairment and a history of aspiration pneumonia. The resident was dependent on tube feeding, and facility policy required gown and glove use for such high-contact care activities. The DON, new to the facility, had not yet addressed the lack of enhanced barrier precautions, and the administrator confirmed responsibility for staff education and monitoring.
A facility failed to update a resident's care plan, leading to severe weight loss and a suicide attempt. The resident exhibited self-isolating behavior and signs of depression, but no care plan was developed to address these issues. The facility's policies on comprehensive, person-centered care plans were not followed, resulting in an Immediate Jeopardy situation.
A resident experienced a severe weight loss of 16.1% over two months due to the facility's failure to follow physician's orders for monthly weights and to address the resident's refusal to eat and take medications. The care plan was not updated, and health shakes were reduced without proper documentation.
A facility failed to provide appropriate treatment and services to a resident with a mental disorder, leading to a suicide attempt. The resident displayed signs of depression and refused psychiatric services and medications, but the facility did not develop or implement a care plan. Staff interviews revealed a lack of proper reporting and documentation of the resident's changes in behavior and mood.
A resident was prescribed Seroquel for behavioral disturbance without a specific diagnosis, contrary to the facility's policy. The medication was administered following an incident where the resident exhibited unusual behavior, but no proper diagnosis was documented. Interviews revealed that the previous DON did not confirm a diagnosis, and the Hospice Medical Director was not properly consulted.
No 24-Hour Licensed Nurse Coverage
Penalty
Summary
The facility failed to have licensed nurses on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans. Record review of the PBJ staffing data report for the fourth quarter of FY 2025 showed no licensed nursing coverage for 24 hours/day on 07/09/25, 07/20/25, 08/02/25, and 09/27/25. The facility policy stated that licensed nurses and certified assistants are available 24 hours a day, seven days a week, and that a licensed nurse is designated as charge nurse on each shift. During interviews, LVN B stated she had not recalled any days during her tenure when the facility lacked licensed nurses and emphasized the importance of 24/7 licensed nurse coverage for resident safety and for carrying out tasks that require a licensed professional. LVN C stated she had never experienced a day without 24-hour licensed nurse coverage during her shifts and noted that many tasks could only be performed by a licensed nurse. The MD stated he was unaware of any lapses in 24/7 licensed nurse staffing and expressed concern that gaps could compromise resident safety. The DON stated she was not aware of any days without licensed nurses, and the ADM acknowledged occasional shortages of LVN coverage until October 2025 but stated there had been no days without licensed nurse coverage since then.
Failure to Maintain RN Coverage and Full-Time DON
Penalty
Summary
The facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week and failed to designate a registered nurse to serve as the director of nursing on a full-time basis for 1 of 1 DON and 1 of 1 RN reviewed for DON and RN coverage. The report states the facility had no DON from 10/01/25 to 11/30/25 and from 12/26/25 to 02/28/26, and that it had no RN coverage on multiple dates in 2025 and no RN coverage since 01/01/26 as of 03/03/26. During interviews, LVN B stated she had concerns about the lack of RN and DON coverage during her tenure and described periods when neither was present. She said that when this occurred, she sought supervisory guidance from physicians, RNs, or DONs at sister facilities, and at times also consulted the pharmacy or dietitian. LVN C stated there had been no consistent RN or DON coverage since she returned to work in October 2025 and that the DONs employed at the facility had short tenures and frequently resigned. The MD stated that many DONs had come and gone and that there were periods when the facility lacked a DON, which he said compromised continuity of care and negatively impacted overall quality. The DON stated she was appointed on 01/29/2026 but did not begin duties until 02/28/2026 because her RN license was overdue for renewal. The ADM stated the recurring shortage of RNs and DONs had been an ongoing issue, that she had requested an RN from sister facilities to serve as an interim DON without success, and that an RN on payroll had been working only when a DON was present because of required clinical supervision related to a prior competency issue.
Failure to Assess and Obtain Consent Before Bed Rail Use
Penalty
Summary
The facility failed to assess residents for the risk of entrapment from bed rails before installing them and failed to review the risks and benefits with the resident or representative and obtain informed consent before use for 5 of 14 residents reviewed for bed rails. The deficiency involved Residents #2, #7, #12, #18, and #26, and the report states that this failure could place residents at risk of entrapment, restraint, and injury. For Resident #2, the record showed diagnoses including cerebral infarction, contracture of the right hand, muscle weakness, and other lack of coordination, with a BIMS score of 12. The resident was documented as her own decision maker. The chart included care plan and restraint assessment entries that did not identify bed rail use, and an order summary later reflected a verbal order for a positioning bar for bed mobility per resident request. However, the record review did not reveal any consent form related to bed rail or grab bar use, and the assessment for safe use of bed rails was not documented. For Resident #7, the record showed diagnoses including chronic respiratory failure, COPD, morbid obesity, and bilateral above-knee amputations, with a BIMS score of 12 and bed rail not in use on the MDS. For Resident #12, the resident had diagnoses including COPD, type 2 diabetes with neuropathy, morbid obesity, and muscle weakness, with a BIMS score of 13 and bed rail not in use on the MDS. For Resident #18 and Resident #26, observations showed bed rails attached to their beds, but the records did not show the required assessment, order, care plan focus, or consent documentation for bed rail, grab bar, or side rail use. The facility’s physician stated he did not recall being consulted for bed rail use and strongly preferred consultation before installation, while the LVN stated bed rail use should involve assessment, orders, care plan documentation, consent, and consultation with therapy, the doctor, the ADM, and the DON. The ADM also stated that orders, documentation, and consents were expected for residents using bed rails.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information that included the facility name, current date, total number and actual hours worked by RNs, LPNs or LVNs, CNAs directly responsible for resident care per shift, and the resident census for 3 reviewed days. During an observation on 03/01/26 at 10:00 a.m., there was no staffing posting present at the facility with the required facility name, date, and staffing details. A later observation and interview on 03/03/26 at 1:25 p.m. confirmed that LVN C searched the nursing station, surrounding area, and various folders but was unable to locate any daily staffing postings. LVN C stated there were no staffing postings for 03/01/16 and 03/02/26 and identified the DON as responsible for ensuring the daily staffing information was posted. During an interview on 03/03/26 at 1:40 p.m., the DON stated she had started on 02/28/26 and was not aware it was her duty to post the daily staffing information. Record review of the facility policy, Staffing, sufficient and competent nursing, revised in August 2022, stated that direct care daily staffing numbers are posted in the facility for every shift.
Inaccurate MDS Did Not Reflect Insulin and Injection Use
Penalty
Summary
The facility failed to ensure that one resident’s quarterly MDS assessment accurately reflected the resident’s status. Resident #8, a male with diagnoses including neurocognitive disorder with Lewy bodies, type 2 diabetes with moderate non-proliferative retinopathy, neuroleptic induced parkinsonism, and acquired absence of the right foot, had a BIMS score of 10, indicating moderate cognitive impairment. The quarterly MDS completed on 12/19/2025 showed 0 injections of any type during the prior seven days and no insulin entries in the insulin section. Record review showed that Resident #8 had active orders for regular insulin on a sliding scale and Trulicity injections, and the care plan documented diabetes management with NCS diet, Trulicity, Jardiance, Metformin, and regular insulin administered on a sliding scale every morning and at bedtime. The MAR for December 2025 showed that insulin and Trulicity injections were administered as ordered during the seven days before the MDS assessment was completed. During interview, the resident stated he was diabetic and received insulin to manage his blood sugar. The MDS assessor confirmed during interview that the resident did receive insulin and injections during the seven days before the quarterly assessment and stated the omission was a mistake and oversight on her part. The LVN and administrator both stated that MDS assessments should accurately reflect residents’ needs and characteristics, including insulin and injection use, and that inaccurate assessments could affect the clinical picture and resident safety. The facility policy and the RAI manual excerpt reviewed in the record stated that staff responsible for MDS completion are trained to ensure accurate assessment and transmission.
CNA failed to use appropriate communication and redirection with residents
Penalty
Summary
The facility failed to ensure nurse aides demonstrated competency in the skills and techniques needed to care for residents safely and in a manner that promoted residents’ rights, physical, mental, and psychosocial well-being. The deficiency involved two residents who were reviewed for competent nursing staff and centered on CNA A’s interaction with a resident who wanted the TV turned on during lunch service. One resident had diagnoses including COPD, Alzheimer’s disease with late-onset dementia, and major depressive disorder, with a BIMS score of 11 indicating moderate cognitive impairment. His care plan directed staff to be conscious of his position in groups, activities, and the dining room to promote proper communication with others. Another resident had diagnoses including type 2 diabetes, COPD, vascular dementia with behavioral disturbance, personality change due to a physiological condition, psychotic disorder with delusions, and major depressive disorder, with a BIMS score of 1 indicating severe cognitive impairment. That resident’s MDS reflected unclear speech, limited ability to express wants, and use of simple, direct communication, and his care plan directed staff to anticipate and meet needs and speak clearly and slowly. During dining room observation, the resident with severe cognitive impairment repeatedly motioned toward the TV and used simple words to ask for it to be turned on. CNA A responded in a belittling tone, telling him, “No! We are not watching TV,” “That is not your TV,” and “You are not watching TV. It’s too loud. We want it quiet,” while taking the remote from his hand and repeating the refusal. The resident continued asking for the TV to be turned on and began wheeling himself toward the TV to turn it on manually. As he did so, the other resident stood up, pointed at him, and said, “Boy, you better not turn on that TV,” then followed him. After the TV was turned on, the other resident pointed his finger in the resident’s face and said, “I’m going to kick your ass.” LVN A later stated the residents should not have been sitting so close together and moved the resident with severe cognitive impairment to another table. She also stated she was unaware whether the behaviors were care planned or what interventions were appropriate for each resident. The AD stated the residents did not typically have issues with each other, that the resident with dementia could be mean or inconsiderate, and that she would have handled the situation differently by turning the TV on for the resident who requested it. The AD stated CNA A escalated the situation by interacting with the residents in a way that increased their behaviors. Record review also showed repeated progress notes for the other resident indicating he needed redirection with instructions during functions. CNA A’s personnel file contained orientation topics related to resident care and dementia care but no indication she reviewed the list or completed a skills check-off, and it also reflected two prior disciplinary actions related to refusal to provide resident care and inappropriate resident interaction and response.
Deficiencies in Food Storage, Equipment Sanitation, and Dishwashing Practices
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in its only kitchen. Observations revealed that multiple food items in the walk-in freezer, walk-in cooler, and side-by-side refrigerator were not labeled with product names or use-by dates. Specifically, bags of frozen chicken, green beans, and cooked bread were found without proper labeling, and one bag of chicken was left unsealed and open to air. Frost and ice buildup were also noted inside the bags, and none of the items had the required information to ensure safe storage and timely use. Additionally, the kitchen's only industrial can opener was found to be unclean, with a black sticky substance present on the underside of the handle mechanism and the piercing metal piece. This residue was easily removed with gloved fingers, indicating a lack of proper cleaning and sanitization. The can opener, which comes into direct contact with food containers, was not maintained in a sanitary condition as required by professional standards and facility policy. The facility's only dishwasher was also found to be deficient, as the sanitizer concentration in the rinse cycle was below the required 50 PPM. Testing with a chemical test strip showed no color change, indicating insufficient sanitizer to properly sanitize dishes. Staff interviews confirmed that food should be labeled and dated, equipment should be kept clean, and the dishwasher should be checked for proper sanitizer levels, but these practices were not consistently followed, leading to the cited deficiencies.
Failure to Use Enhanced Barrier Precautions During Tube Feeding
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by the Director of Nursing (DON) not using enhanced barrier precautions during a gastrostomy feeding for a resident. Specifically, during an observed gastric tube bolus feeding, the DON did not don a gown prior to administering the feeding, which was required by the facility's policy for high-contact resident care activities involving device care such as feeding tubes. The resident involved was a female with severe cognitive impairment, a history of aspiration pneumonia, and was dependent on tube feeding for nutrition and hydration. Interviews revealed that the DON, who had recently started employment, was aware that enhanced barrier precautions were not being implemented but had not yet addressed the issue due to working as a charge nurse. The administrator, who also served as the infection preventionist, confirmed responsibility for staff education and monitoring of enhanced barrier precautions, and acknowledged that gown and gloves should be used during such high-contact activities. Facility policy required the use of gown and gloves for device care to prevent the spread of multi-drug resistant organisms.
Failure to Implement Comprehensive Care Plan Leads to Resident's Suicide Attempt
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident, leading to severe weight loss and a suicide attempt. The resident, who had diagnoses including hypertension, cardiomyopathy, and hyperlipidemia, experienced a 16.1% weight loss and refused to eat over a two-month period. Despite physician orders for monthly weight checks and health shakes, the care plan was not updated to address these issues. Additionally, the resident exhibited self-isolating behavior, blocked his room door, and showed signs of depression, but no care plan was developed to address these behaviors. This culminated in the resident attempting suicide by cutting his wrists with broken glass from a picture frame. The resident's progress notes indicated that he had turned his bedside table upside down to block his door and believed his TV was brainwashing him. Despite these clear signs of distress, no care plan was developed to address his mental health needs. On the day of the suicide attempt, the resident was found with lacerations on his wrists and blood on the floor. He admitted to trying to kill himself and expressed feelings of guilt and distress over a past inappropriate relationship. The facility's failure to update the care plan to address these behaviors and mental health issues directly contributed to the resident's suicide attempt. Interviews with staff revealed that the MDS nurse worked off-site and did not know the residents, leading to delays in updating care plans. The Director of Nursing (DON) and the Administrator acknowledged that care plans should be updated within 24 hours of a significant change in condition. However, this was not done for the resident in question. The facility's policies on comprehensive, person-centered care plans were not followed, resulting in an Immediate Jeopardy situation that placed residents at risk for accidents, diminished quality of life, and suicide.
Failure to Maintain Nutritional Status
Penalty
Summary
The facility failed to ensure that a resident maintained acceptable parameters of nutritional status, resulting in a severe weight loss of 16.1% over a two-month period. The resident, who had diagnoses including hypertension, cardiomyopathy, hyperlipidemia, and protein-calorie malnutrition, was not weighed monthly as per the physician's orders. Additionally, the facility did not document a weight taken on 01/16/2024 and failed to identify a decrease in the administration of health shakes from three times a day to two times a day. The resident's care plan did not include updated weights or address the resident's refusal to eat and take medications. Despite multiple progress notes indicating the resident's refusal to eat and take medications, the facility did not take timely action to address these issues. Interviews with staff revealed that the resident often refused meals and health shakes, and no substitutions were provided. The dietician confirmed that a nutritional assessment showed weight loss, but weekly weights were not consistently conducted. The facility's Director of Nursing (DON) and other staff members acknowledged that proper monitoring and documentation of the resident's weight were not performed. The facility's policy required the nursing staff to monitor and document weight and dietary intake, but this was not followed. The failure to monitor and address the resident's weight loss led to the identification of an Immediate Jeopardy situation, which was later removed after corrective actions were initiated.
Failure to Address Resident's Mental Health Needs
Penalty
Summary
The facility failed to ensure a resident diagnosed with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services. The resident, who had a history of hypertension, cardiomyopathy, and hyperlipidemia, displayed signs of depression and refused psychiatric services and medications on multiple occasions. Despite these signs, the facility did not develop or implement a care plan to address the resident's mental health needs, nor did they document any attempts to provide or encourage psychiatric treatment. This lack of action persisted even after the resident expressed feelings of being tired and ready to die to a CMA, who failed to report these statements to the appropriate staff. The resident's condition deteriorated further, culminating in a suicide attempt. On one occasion, the resident was found with lacerations on both wrists and blood on the floor, having used broken glass from a picture frame to harm himself. The resident expressed feelings of guilt and mentioned a troubled relationship with his RP, which he believed was the reason for his distress. Despite these clear signs of severe mental distress, the facility's staff did not take timely or adequate measures to address the resident's mental health needs. Interviews with various staff members, including LVNs, CNAs, and the DON, revealed a lack of proper reporting and documentation of the resident's changes in behavior and mood. The facility's policy on behavioral health services was not followed, leading to a failure in providing the necessary care and treatment for the resident's mental and psychosocial well-being. This deficiency placed the resident at significant risk, ultimately resulting in a serious incident that could have been prevented with appropriate intervention and care planning.
Inappropriate Prescription of Seroquel Without Specific Diagnosis
Penalty
Summary
The facility failed to ensure that a resident was prescribed Seroquel for a specific diagnosis, instead prescribing it for behavioral disturbance at bedtime. This failure was identified during a review of the resident's medical records and interviews with facility staff. The resident, an elderly male with moderate cognitive impairment, was noted to have no hallucinations or delusions that would indicate psychotic behaviors. Despite this, the resident was prescribed Seroquel following an incident where he turned his overbed table upside down and placed it in front of his door, believing his TV was brainwashing him. The facility did not place the resident on one-to-one supervision and instead opted to administer Seroquel without a specific diagnosis documented in the clinical record. The medication was continued for several days without adverse reactions noted, but the lack of a proper diagnosis was a significant oversight. Interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed that the previous DON, who was no longer employed, had not confirmed a diagnosis for the Seroquel prescription. The Hospice Medical Director was also not properly consulted for a specific diagnosis. The facility's policy on antipsychotic medication, which requires medications to be clinically indicated to treat a specific condition, was not followed. The resident's medical records showed no diagnosis of psychosis, schizophrenia, bipolar disorder, anxiety, depression, or insomnia, making the prescription of Seroquel inappropriate according to the facility's policy.
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 41 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Meridian
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willow Park Rehabilitation Health Care Center | 10.8 mi | ★★★★★ | 15 | 1 |
| Sunset Home | 11.8 mi | ★★★★★ | 0 | 0 |
| Goodall Witcher Nursing Facility | 13.2 mi | — | 0 | 0 |
| Whitney Nursing And Rehabilitation Center | 20 mi | ★★★★★ | 2 | 0 |
| Cherokee Rose Nursing And Rehabilitation | 21.3 mi | ★★★★★ | 11 | 0 |
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