Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hilltop Healthcare Rehabilitation And Skilled Nurs during CMS and state inspections, most recent first.
The facility did not consistently offer or provide substantial bedtime snacks to residents, resulting in a prolonged period between dinner and breakfast. Several residents reported that snacks were not delivered or were insufficient, and staff interviews confirmed that snacks were only available upon request, with no routine snack cart service. This practice did not align with the facility's policy and had the potential to affect all residents.
A resident with multiple medical conditions was prescribed duloxetine and pristiq without any documented indication for use. Both an RN and the DON confirmed that these psychotropic medication orders did not include the required indication, which was inconsistent with facility policy.
The facility failed to ensure accurate MDS coding for three residents, including errors in documenting hospice services, colostomy status, and use of mobility devices. Staff interviews and record reviews confirmed that the assessments did not accurately reflect the residents' actual conditions at the time.
A resident with multiple mental health diagnoses was admitted for post-hospital rehabilitation with a Level II PASARR assessment limited to 30 days. When the resident's stay exceeded this period, facility staff failed to conduct or document the required reassessment, as they were unaware of the 30-day limitation and the need for further evaluation, resulting in unmet requirements for addressing the resident's mental health needs.
Two residents with complex pain and wound care needs did not have individualized or comprehensive care plans. One resident's plan lacked specific details on pain assessment, goals, and non-pharmacologic interventions, while another's plan did not address actual wound conditions, individualized positioning, or coordination with outside wound care providers, despite relevant provider orders and staff acknowledgment of these needs.
A resident with COPD, depression, and pressure ulcers did not receive required quarterly care conferences, with documentation showing only two conferences and no further records. The resident recalled only one care conference, and staff confirmed that additional conferences were missed, possibly due to hospitalizations. Facility policy requires quarterly interdisciplinary care plan reviews, which were not completed for this resident.
A resident with heart failure and other chronic conditions did not have daily weights completed as ordered, with only a few weights documented for the month and no record of refusals. Additionally, there was no assessment or documentation prior to the resident being sent to the ER for leg pain and edema, despite staff expectations for such documentation.
A resident with chronic kidney disease and other comorbidities did not have vital signs assessed before or after dialysis sessions. Staff interviews confirmed that vital sign assessments were not routinely performed upon the resident's return from dialysis, and the facility's care plan and policy did not address this requirement.
A nurse administered insulin to a resident with diabetes by drawing doses from insulin pens into a syringe, rather than using the pens as intended, while failing to change gloves or perform hand hygiene and leaving the medication cart and medications unattended. The resident expressed concern about the accuracy of the dose and the method used, and facility policies did not support the nurse's actions.
Two residents were found to have medication orders without proper indications or diagnoses attached, including multiple medications for a resident with severe cognitive impairment and a valacyclovir order for another resident with psychiatric and medical conditions. Both nursing staff and the DON confirmed that all medication orders are expected to have an associated diagnosis or indication, in line with facility policy.
Staff failed to keep medication carts locked and medications secured, leaving narcotics and other prescription drugs unattended and accessible in resident areas. On multiple occasions, medication carts were left unlocked, and medications such as insulin pens were left unattended at the desk, contrary to facility policy requiring locked storage.
A resident with moderate cognitive impairment and a history of falls was injured during a transfer when staff failed to use a gait belt as required by the care plan. The resident fell, resulting in multiple rib fractures, a pneumothorax, and a hemothorax, requiring emergency medical treatment. Staff interviews confirmed awareness of the resident's tendency to lean backwards, which increased fall risk, but the care plan was not followed, leading to the incident.
A resident's POLST indicating full CPR was not followed when the resident was found unresponsive without a pulse. An LPN failed to initiate CPR or verify the resuscitation status promptly, leading to a delay in life-saving measures. The resident was pronounced deceased by EMS upon their arrival.
Two residents requiring 1:1 supervision during meals were left unsupervised, leading to choking risks. One resident with dysphagia experienced multiple coughing episodes and a severe choking incident, while another was found asleep with food in his mouth. Staff failed to follow care plans and therapy recommendations, resulting in immediate jeopardy.
The facility did not ensure that two nursing assistants completed the required 12 hours of annual in-service training. One assistant completed 8.57 hours, and another completed 3.5 hours. Despite daily reminders, one assistant forgot to complete the necessary modules. The DON and administrator expected all assistants to fulfill their training requirements annually.
The facility did not provide mandatory QAPI training to staff, as confirmed by interviews with a nursing assistant, an LPN, and an RN, who were unaware of the QAPI plan. The DON acknowledged the need for staff education, and the administrator admitted the lack of formal training. A review of the Relias training program showed no QAPI training for employees.
Failure to Routinely Offer and Provide Substantive Bedtime Snacks
Penalty
Summary
The facility failed to consistently offer and provide a substantive, nutrient- and calorie-rich snack to residents after the dinner meal and before bedtime, resulting in a gap of up to 15 hours between the evening and morning meals. Multiple residents with intact cognition reported during interviews and a resident council meeting that staff did not deliver bedtime snacks, snacks were not substantial, and there was insufficient variety or quantity. Staff interviews revealed that snacks were available on the unit, but residents had to request them, and there was no routine snack cart service. Some staff were unaware of the existence of snack carts, and the DON stated that the expectation was for snacks to be offered before bedtime. Meal delivery times for each unit were documented, showing dinner was served in the early evening and breakfast the following morning, confirming the extended period without food. The facility's Snack Availability policy stated that residents should have access to nourishing snacks, defined as verbal offerings from basic food groups, but the practice did not align with this policy. The deficiency had the potential to affect all 107 residents in the facility.
Psychotropic Medication Orders Lacked Indication for Use
Penalty
Summary
The facility failed to ensure that psychotropic medication orders included an indication for use for one resident. Record review showed that a cognitively intact resident with multiple diagnoses, including depression, anxiety, polyneuropathy, hypertension, and amputation, had active orders for duloxetine and pristiq without any listed indication for use. During interviews, both a registered nurse and the director of nursing confirmed that these medication orders lacked an indication, which was contrary to facility policy requiring every medication order to have an associated indication or diagnosis. The facility's medication administration policy also specified that staff should be able to state the indication for each medication administered.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to ensure accurate coding of the Minimum Data Set (MDS) for three residents, resulting in assessments that did not reflect the residents' actual status at the time of completion. For one resident, the admission MDS was incorrectly coded to indicate the resident was not receiving hospice services, despite census documentation and the care plan confirming hospice care at admission. Both the RN and DON acknowledged that the MDS should have reflected hospice services. Another resident's quarterly MDS was marked as having a colostomy in Section H, but interviews with nursing staff confirmed the resident did not have a colostomy, and the MDS nurse admitted this was an error. A third resident's quarterly MDS indicated no use of mobility devices, despite the resident having a history of lower limb amputation and being observed with a wheelchair and prosthetic leg in the room. The resident confirmed using these devices when out of bed, and the MDS coordinator acknowledged the MDS was inaccurate. The DON confirmed the expectation that MDS reports should accurately reflect the resident's status and that the MDS in question was not accurate regarding mobility devices. These findings were based on record review, staff interviews, and direct observation.
Failure to Complete Required PASARR Reassessment After 30 Days
Penalty
Summary
A deficiency occurred when the facility failed to ensure a required Level II Pre-Admission Screening and Resident Review (PASARR) reassessment was conducted, documented, and retained for a resident with multiple mental health diagnoses. The resident, who had severely impaired cognition and required substantial assistance with most activities of daily living, was admitted with diagnoses including dementia with agitation, delusional disorder, bipolar disorder, depression, and schizophrenia. The initial PASARR Level II assessment approved admission for post-hospital rehabilitative services for 30 days, with instructions that further assessment and service plan changes must be documented if the resident's stay exceeded 30 days or if there was a change in condition. Despite these requirements, the facility did not complete or document a PASARR reassessment after the resident remained in the facility beyond the approved 30-day period. Interviews with the admissions clerk, social services director, and director of nursing revealed that none were aware of the 30-day limitation on the Level II assessment or the need to notify the appropriate agency for reassessment. As a result, the resident's mental health needs may not have been appropriately addressed or provided for during their extended stay.
Failure to Develop Individualized and Comprehensive Care Plans for Pain and Wound Management
Penalty
Summary
The facility failed to develop individualized and comprehensive care plans for two residents with needs related to pain and wound management. For one resident with diagnoses including malignant neoplasm of the prostate, chronic pain syndrome, and anxiety, the care plan did not clearly identify the presence of pain, lacked individualized details on pain assessment, did not specify a goal for pain tolerance, and omitted how pain impacted sleep, activities of daily living, leisure activities, mood, or behavior. Provider orders included scheduled and as-needed morphine, but there were no documented non-pharmacologic interventions. Interviews revealed that non-pharmacologic strategies were not consistently implemented or documented, and the care plan was not updated to reflect the resident's specific pain symptoms and interventions. For another resident with bilateral lower extremity cellulitis, thoracic spine pain, and chronic pulmonary edema, the care plan identified a general problem with skin integrity but did not specify the presence of venous stasis or pressure ulcers. The interventions listed were generic and did not include individualized instructions for positioning, a turning and repositioning program, or coordination with the outside wound care provider, despite provider orders and documentation indicating the need for these measures. Interviews with nursing staff confirmed the importance of individualized positioning and turning for this resident, but the care plan did not reflect these needs.
Missed Quarterly Care Conferences for Resident
Penalty
Summary
The facility failed to ensure that quarterly care conferences were completed for a resident with diagnoses of COPD, depression, and pressure ulcers. Documentation showed that the resident had care conferences on two occasions, but no further conferences were documented as required. The resident reported only recalling one care conference since admission. The social services director confirmed that the last care conference occurred several months prior and acknowledged that subsequent conferences were missed, possibly due to the resident's hospitalizations. The director of nursing stated that care conferences should occur quarterly and after a change in condition, emphasizing their importance in developing individualized care plans. Facility policy requires quarterly interdisciplinary care plan reviews and conferences, but this was not followed for the resident in question.
Failure to Complete Ordered Weights and Document Assessment Prior to ER Transfer
Penalty
Summary
The facility failed to ensure that a resident with multiple chronic conditions, including congestive heart failure, chronic obstructive pulmonary disease, morbid obesity, obstructive sleep apnea, hypertension, and chronic kidney disease, received care and treatment according to physician orders and care plan interventions. Specifically, the resident had provider orders for daily weights and fluid restriction, as well as multiple diuretic medications. However, the electronic medical record for April did not show that weights were taken as ordered, with only three weights documented for the entire month. There was no documentation of the resident refusing weights or any progress notes explaining missed weights. Additionally, prior to the resident being sent to the emergency department for leg pain and edema, there was no assessment or documentation in the medical record regarding the resident's symptoms or the decision to transfer. Observations noted the resident had significant lower extremity edema and pain, and interviews with staff confirmed that documentation and assessment were expected but not completed. The director of nursing and registered nurse both acknowledged that daily weights and documentation of refusals or assessments prior to ER transfer should have occurred.
Failure to Assess Pre- and Post-Dialysis Vital Signs
Penalty
Summary
The facility failed to ensure that vital signs were assessed before and after dialysis for a resident with multiple chronic conditions, including chronic kidney disease, atrial fibrillation, coronary artery disease, diabetes mellitus, and hypertension. The resident's care plan included interventions for monitoring the dialysis access site but did not address the need for pre- and post-dialysis vital sign assessments. Documentation for April 2025 did not show any record of vital sign assessments before or after dialysis sessions. Interviews with the resident and staff revealed that vital signs were not routinely taken upon the resident's return from dialysis, and staff were unaware of any requirement to do so. The trained medication aide confirmed that no assessment was performed after dialysis, and the registered nurse stated that only the dialysis site was checked, with vital signs being taken at the dialysis facility. The director of nursing acknowledged that pre- and post-dialysis vital signs should be taken to monitor for complications, but this was not reflected in practice or in the facility's dialysis policy, which did not address vital sign assessments.
Improper Insulin Administration and Infection Control Lapses
Penalty
Summary
A nurse failed to competently administer insulin to a resident with diabetes, as evidenced by video footage and interviews. The nurse, while wearing the same pair of gloves throughout the process, handled multiple surfaces, medication drawers, and insulin pens without changing gloves or performing hand hygiene. The nurse drew insulin from two different insulin pens into a syringe and administered two injections to the resident, rather than using the insulin pens as intended. The medication cart and insulin pens were left open and unattended during the process, contrary to facility policy. The resident, who was cognitively intact and had a diagnosis of type II diabetes, expressed concern about the insulin administration, specifically suspecting that the nurse may have miscalculated the dose and administered too much insulin. The resident reported experiencing a low blood sugar episode that night, although this was not documented in the vitals summary. The resident also noted that the nurse appeared unsure during the administration and that the method used—drawing insulin from pens into a syringe—was not appropriate. Interviews with the nurse, the DON, and the consulting pharmacist confirmed that drawing insulin from an insulin pen with a syringe is not an acceptable practice and is not included in the facility's competency checklist or policy. The nurse acknowledged the improper technique and infection control lapses, and the DON confirmed that the medication cart and medications should not be left unlocked or unattended. Facility policies reviewed did not support the actions taken by the nurse during the insulin administration.
Failure to Document Indications for Medication Orders
Penalty
Summary
The facility failed to ensure that all medication orders for two residents included a proper indication or diagnosis for use, as required. For one resident with severe cognitive impairment and multiple diagnoses including cerebrovascular disease, dementia, hypertension, depression, hyperlipidemia, and a history of transient ischemic attack, provider orders for several medications such as aspirin, atorvastatin, clopidogrel, losartan, and pantoprazole did not have an associated indication or diagnosis. This was confirmed during a review of the resident's chart by a registered nurse, who acknowledged the absence of proper indications for these medications. For another resident with diagnoses of bipolar disorder, PTSD, and chronic pancreatitis, a provider order for valacyclovir also lacked a documented diagnosis or indication for use. The DON confirmed the expectation that all medication orders should have a diagnosis or indication attached. The facility's medication administration policy requires staff to be able to state the indication for all medications, but this was not followed in these cases.
Medications Left Unsecured and Medication Carts Unlocked
Penalty
Summary
Facility staff failed to ensure that medications and biologicals were securely stored in accordance with professional standards and facility policy. On multiple occasions, medication carts containing narcotics and other prescription medications were observed to be left unlocked and unattended in resident-accessible areas. Specifically, a medication cart was found unlocked and unattended by the DON, who confirmed the incident with the trained medication administrator (TMA). The TMA acknowledged leaving the cart unsecured, which contained medications such as gabapentin and muscle relaxants. Additionally, video footage reviewed by the DON showed a nurse leaving the medication cart open and unlocked while administering insulin to a resident, and also leaving insulin pens unattended at the desk. The facility's policy required all medications to be stored in locked compartments, with controlled substances requiring two locks. These observations and interviews confirmed that staff did not consistently follow procedures for securing medications, resulting in medications being left accessible to unauthorized individuals.
Failure to Implement Care Plan Leads to Resident Injury
Penalty
Summary
The facility failed to implement care plan interventions for a resident who required the use of a transfer belt during transfers, resulting in a fall and significant injuries. The resident, who had moderate cognitive impairment and required assistance with various activities of daily living, was being assisted to the bathroom by a nursing assistant. During the transfer, the nursing assistant held onto the resident's pants instead of using a gait belt, as specified in the care plan. This led to the resident falling backwards and sustaining multiple rib fractures, a pneumothorax, and a hemothorax, necessitating emergency medical treatment. The resident's care plan clearly indicated the need for a gait belt during transfers due to the resident's tendency to lean backwards, which increased the risk of falls. Despite this, the nursing assistant did not use the gait belt, resulting in the resident's fall. The physical therapy assistant and registered nurse confirmed that the resident's backward lean was a known issue, and the use of a gait belt was emphasized to provide better control during transfers. Interviews with staff revealed that the nursing assistant was aware of the resident's tendency to lean backwards but failed to follow the care plan by not using the gait belt. The director of nursing confirmed that the care plan was not followed, which contributed to the fall and subsequent injuries. The facility's gait belt and care plan policies were requested but not provided, indicating a lack of documentation to support proper procedures.
Failure to Follow POLST and Initiate CPR
Penalty
Summary
The facility failed to follow a Physician Orders for Life-Sustaining Treatment (POLST) for a resident who wished to have cardiopulmonary resuscitation (CPR) in the event of cardiopulmonary arrest. The resident was found unresponsive, without a pulse or respirations, by an LPN who did not initiate CPR as per the resident's POLST. The LPN left the room multiple times and communicated with other staff members but did not take action to start CPR or call for emergency assistance. The resident was eventually pronounced deceased by emergency medical services. The incident was further compounded by the LPN's failure to verify the resident's resuscitation status promptly, despite being advised by other staff members to do so. The Director of Nursing was informed of the situation and upon arrival, confirmed the resident's full code status and initiated CPR with the assistance of another RN. However, by the time CPR was started, the resident was already deceased. The facility's CPR procedure was not followed, leading to a delay in providing life-saving measures to the resident.
Removal Plan
- Reviewed their policy and procedure on CPR, and re-educated all staff on the CPR policy and procedure.
- Assessed all residents to ensure their POLST were completed and accurate.
- Conducted a mock CPR drill during morning and evening shift to ensure staff respond correctly.
- Reviewed the daily schedule to ensure each shift had at least three staff of nurses or TMAs who were CPR certified.
- Completed audits to ensure all crash carts had all essential equipment and supplies, and the AED was functional and will bring the results of the audits to the Quality Assurance and Performance Improvement (QAPI) committee.
Failure to Provide 1:1 Supervision During Meals
Penalty
Summary
The facility failed to provide proper supervision during meals for two residents who required 1:1 supervision to prevent choking. Resident 1 had a history of dysphagia and required close supervision during meals to prevent choking. Despite this, there were multiple instances where Resident 1 was left unsupervised during meals, leading to coughing episodes and a severe choking incident on medications. The staff failed to adhere to the care plan and therapy recommendations, which required 1:1 supervision and cues to ensure safe eating practices. Resident 2, who had aphasia and required 1:1 supervision during meals, was also left unsupervised. On one occasion, Resident 2 was found asleep at the dining table with food in his mouth, unresponsive to initial attempts to wake him. Despite therapy recommendations for 1:1 supervision, staff did not consistently provide the necessary oversight, leaving Resident 2 at risk of choking and aspiration. The facility's failure to provide adequate supervision during meals for these residents resulted in immediate jeopardy. Staff were aware of the supervision requirements but did not consistently implement them, leading to potentially dangerous situations for both residents. The lack of documentation and communication among staff further contributed to the deficiency, as incidents were not properly recorded or addressed in a timely manner.
Removal Plan
- The facility reviewed and revised their current policy on meal assistance.
- The facility reviewed all resident care plans/Kardex to reflect current ST recommendations.
- The facility implemented a new system for therapy recommendations.
- The facility completed staff education on the meal assistance policy with post quiz.
- The facility completed audits on all residents who needed assistance or supervision with meals to ensure they were being assisted or supervised.
Deficiency in Annual Training for Nursing Assistants
Penalty
Summary
The facility failed to ensure the completion of 12 hours of annual in-service training for two of the five nursing assistants reviewed. NA-A had completed only 8.57 hours, while NA-D had completed 3.5 hours of the required training within the last 12 months. Despite being reminded almost daily by the facility, NA-A forgot to complete the necessary modules, resulting in overdue training. The Director of Nursing and the administrator both stated that all nursing assistants were expected to complete their 12 hours of training each year by the due date.
Lack of QAPI Training for Staff
Penalty
Summary
The facility failed to provide mandatory training on its Quality Assurance and Performance Improvement (QAPI) program to all staff. During interviews, a nursing assistant, a licensed practical nurse, and a registered nurse all stated they did not recall receiving any QAPI training and were unaware of the facility's QAPI plan or how to communicate concerns related to it. The director of nursing acknowledged that all staff should be educated on QAPI, while the administrator admitted that although QAPI is often discussed, there has been no formal education provided to staff. A review of the facility's Relias training program confirmed the absence of QAPI training for employees.
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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 Duluth
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Benedictine Health Center | 1.3 mi | — | 22 | 2 |
| Aftenro Home | 1.7 mi | — | 17 | 0 |
| Viewcrest Health Center | 2.9 mi | — | 0 | 0 |
| Bayshore Residence And Rehabilitation Center | 4 mi | — | 2 | 0 |
| Ecumen Lakeshore | 4 mi | — | 0 | 0 |
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