Inspection visit
Inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0921
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and
the public.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to maintain a safe, sanitary, and comfortable
environment by failing to prevent ongoing water leakage through the roof and mold-like growth in the
shower rooms and on ceiling tiles. This failure has the potential to affect all 62 residents residing in the
facility.
Findings Include:
On [DATE] at 9:35 AM there was black mold-like substance on the East Hall shower room ceiling vent grate.
There was also black and orange mold-like substance on the shower stalls wall and floor. The caulk was
peeling off and the black mold like substance was growing underneath.
On [DATE] at 9:40 AM one 2'x2' ceiling tile in front of room [ROOM NUMBER] and 106 was missing and the
tile next to that spot appeared to have been saturate with water at one point, was bulging downward
towards the floor and was discolored and brown.
On [DATE] at 9:46 AM two 2'x2' ceiling tiles in front of room [ROOM NUMBER] and 108 were missing and
four ceiling tiles around that spot had brown water-like spots on them.
On [DATE] at 9:54 AM two 2'x2' ceiling tiles in front of room [ROOM NUMBER] were completely missing.
On [DATE] at 9:57 AM there was black mold-like substance on both of the [NAME] Hall shower room ceiling
vent grates. There was also black and orange mold-like substance on the shower stalls wall and floor. The
caulk was peeling off and the black mold like substance was growing underneath.
On [DATE] at 10:01 AM one 2'x2' ceiling tile was missing by the [NAME] Hall nurses station.
On [DATE] at 10:03 AM one 2'x2' ceiling tile was missing in front of room [ROOM NUMBER] and 213 and
the surrounding tiles had brown water-like spots on them.
On [DATE] at 10:06 AM one 2'x2' ceiling tiles at the end of the [NAME] Hall by the exit door had brown
water-like spots on them and one corner had black and pink mold-like substance growing on it.
The facility Resident Council Minutes for the month of [DATE] document resident complaints of the roof
leaking and needs fixed.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
145862
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145862
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/27/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hilltop Skilled Nsg & Rehab
910 West Polk Street
Charleston, IL 61920
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0921
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
On [DATE] at 10:10 AM both R2 and R3 stated the roof had been leaking in the facility for a couple months.
Both R2 and R3 stated they think V7 Maintenance was trying to patch it but it was not working and only
getting worse. Both R2 and R3 stated they had used their own trash can once the week before when it was
leaking to help catch the water so it didn't get all over the floor and create a hazard. Both R2 and R3 stated
they had seen mold-like substances growing in the shower rooms. Both R2 and R3 agreed that these
issues needed to be addressed in a more thorough fashion.
On [DATE] at 8:05 AM V3 Licensed Practical Nurse stated the roof has been leaking for a couple of months
but has gotten worse. V3 stated the leaking is happening down the East and [NAME] Hallways and is not
getting fixed properly. V3 stated staff put out buckets to catch the water when it leaks.
On [DATE] at 8:15 AM V4 [NAME] stated the roof has been leaking for a few months. V4 stated the
maintenance department tries to repair it but it is not working and they need a professional roofing
company.
On [DATE] at 8:30 AM V5 Licensed Practical Nurse stated the roof is leaking but she does not know for how
long. R5 stated the staff set out buckets to catch the water.
On [DATE] at 8:47 AM V6 Certified Nurses Assistant stated the roof has been leaking for a couple of
months but has gotten worse. Staff put out buckets to catch the water.
On [DATE] at 9:30 AM V8 Housekeeper stated the roof has been leaking for a few months on East and
[NAME] halls. V8 confirmed she has seen a mold-like substance in the [NAME] Hall shower room stall and
has tried to clean it but it does not get rid of it for good.
On [DATE] at 9:43 AM V9 Activities Assistant stated the roof has been leaking and staff use trash cans to
catch the water.
On [DATE] at 10:01 AM V10 Licensed Practical Nurse and V11 Certified Nurses Assistant stated the roof
has been leaking pretty badly down [NAME] Hall and on East Hall. Staff use buckets to catch water and try
to prevent water hazards.
On [DATE] at 8:50 AM V1 Administrator confirmed the roof has been leaking. V1 was not sure about a time
frame but felt a couple months sounded accurate. V1 stated the roof leaks down the East and [NAME]
Halls. V1 Administrator confirmed the facility census was 62.
On [DATE] at 8:58 AM V7 Maintenance Director stated the roof has been leaking for about a year. V7 stated
it has gotten worse in the last few months. V7 stated he has patched it several times however it is not
working. V7 confirmed the leaking occurs down the East and [NAME] hallways and is a steady drip when it
is raining. V7 confirmed the removed ceiling tiles in the building are areas where water has been leaking
through. V7 confirmed some tiles have water spots from getting wet. V7 confirmed the shower room stalls
need to be cleaned more thoroughly and currently have a black and orange mold-like substance growing on
them. V7 confirmed the shower room vent grates also have a black mold-like substance on them. V7 stated
the facility does have a plan to have a roofing company come and do professional repairs but is not sure
when that will be exactly.
On [DATE] at 10:57 AM V12 Corporate Maintenance Director stated the facility has been struggling with it's
roof leaking for quite some time and the issues is ongoing. V12 confirmed the issues has gotten worse as
of recently with all of the rain and snow. V12 stated the facility just had a
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145862
If continuation sheet
Page 2 of 3
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
145862
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/27/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Hilltop Skilled Nsg & Rehab
910 West Polk Street
Charleston, IL 61920
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0921
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
FORM CMS-2567 (02/99)
Previous Versions Obsolete
professional roofing company come out to do an estimate for repairs or replacement. V12 stated the plan is
to get the roof repaired or replaced by this Spring. V12 stated the facility's housekeepers have the right
products to properly clean the showers and if done correctly the facility should not have any mold-like
substances growing in the shower stalls. V12 confirmed he would be talking with facility maintenance and
housekeeping in order to get the items cleaned or replaced if needed. V12 confirmed the staff should have
remedied these issues.
Event ID:
Facility ID:
145862
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F921 - Other Environmental Conditions
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
FAQ · About this visit
Common questions about this visit
What happened during the January 27, 2024 survey of HILLTOP SKILLED NSG & REHAB?
This was a inspection survey of HILLTOP SKILLED NSG & REHAB on January 27, 2024. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at HILLTOP SKILLED NSG & REHAB on January 27, 2024?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.