Inspection·February 26, 2024

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to provide denture care assistance for two (R1 and R3) of three residents reviewed for activities of daily living from a total sample list of seven residents reviewed. Residents Affected - Few Findings include: The undated facility policy documents that denture care is to be provided before breakfast and at bedtime. The resident is to be encouraged and assisted as needed. As denture care is provided, examination of the resident's mouth and gums for paleness, mouth sores, bleeding or areas of discoloration should be done. Encourage the resident to perform as much of the procedure as possible. 1.) R1's admission assessment dated [DATE] documents that R1 admitted to the facility with upper and lower dentures. R1's updated care plan does not document denture care. On 2/26/24 at 8:50AM, V4 Certified Nursing Assistant (CNA) stated that morning cares consist of washing (the residents) up, making sure they have their call lights, brushing their teeth, cleaning their dentures, and brushing their hair and if they can do it on their own, we still take a look and to make sure that it was done. On 2/26/24 at 8:45AM, R1 was sitting in his room in a wheel chair eating his breakfast while wearing dentures. A denture cup was sitting on his bedside table. On 2/26/24 at 9:30AM, R1 stated, They don't clean my dentures here. I usually leave them in all the time. When I was at the hospital, they told me that I have to take them out and clean them once in awhile. They cleaned them when I was in the hospital and they haven't been cleaned since. On 2/26/24 at 8:55AM, V5 CNA stated that she usually works on the 200 hall and that she didn't help R1 with his dentures today because he doesn't have dentures. On 2/26/24 at 8:56AM, V4 stated that she usually works the 200 hall and that she has never reminded R1 to clean his dentures because he doesn't have dentures. On 2/26/24 at 8:57AM, V6 Licensed Practical Nurse stated that she was R1's nurse and that she was not aware that R1 had dentures. (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 2 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 02/26/2024 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)