Inspection·February 11, 2026

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the safety of four (R1, R2, R4, R5) residents through the use of extension cords for medical devices out of four residents reviewed for physical environment in a sample list of five residents. Findings include:1.R1's Electronic Medical Record (EMR) documents medical diagnoses as Obstructive Sleep Apnea, Chronic Respiratory Failure, Heart Failure and Atrial Fibrillation.R1's Minimum Data Set (MDS) dated [DATE] documents R1 as cognitively intact.On 2/6/26 at 3:33 PM, R1's Nebulizer machine, Oxygen concentrator and BI-PAP machine were all plugged into an outlet strip extension cord which was plugged into the wall outlet. R1 stated she only has one outlet, so her bed and the extension cord is plugged into her outlet. 2.R2's Electronic Medical Record (EMR) documents medical diagnoses as Asthma, Morbid Obesity, Atrial Fibrillation, Pericardial Effusion, Obstructive Sleep Apnea, Heart Failure, Cardiomyopathy, Chronic Respiratory Failure and Hypoxia.R2's Minimum Data Set (MDS) dated [DATE] documents R2 as cognitively intact.On 2/6/26 at 3:15 PM, R2's pacemaker monitor, and Nebulizer machine were plugged into an outlet strip extension cord that was attached to the wall beside her window. R2 pointed to her extension cord and stated, 'that looks like a fire hazard to me, but what do I know'. 3.R4's Electronic Medical Record (EMR) documents medical diagnoses as Chronic Respiratory Failure, Obstructive Sleep Apnea, Tachycardia and Chronic Obstructive Pulmonary Disease (COPD)R4's Minimum Data Set (MDS) dated [DATE] documents R4 as cognitively intact. On 2/10/26 at 3:15 PM, R4's BI-PAP and Nebulizer machine was plugged into an outlet strip extension cord which was plugged into the wall outlet. R4's Oxygen concentrator was plugged into a separate outlet strip extension cord behind her recliner chair. 4.R5's Electronic Medical Record (EMR) documents medical diagnoses as Obstructive Sleep Apnea, Chronic Obstructive Pulmonary Disease (COPD), Malignant Neoplasm of Bronchus and Lung, Pulmonary Fibrosis, Emphysema and Chronic Pulmonary Edema.R5's Minimum Data Set (MDS) dated [DATE] documents R5 is cognitively intact. On 2/10/26 at 10:00 AM, R5's Oxygen concentrator was plugged into an outlet strip extension cord. R5 stated she sometimes puts her Nasal Cannula on or takes it off ‘but I never mess with the plug ins'. On 2/10/26 at 2:45 PM, V5 Maintenance Director stated the room outlets are going to be changed to hospital grade circuit breaker types over a period of time. V5 stated once the outlets are changed out residents will have more outlets to plug medical devices into. V5 stated there is really no other way around this situation other than to change out all of the electrical outlets across the facility. V5 stated plugging in multiple medical devices that require more of an electrical draw into an outlet strip that is plugged into the wall outlet could be a fire hazard. On 2/10/26 at 3:00 PM, V1 Administrator stated the facility is in the process of changing all the electrical outlets as a concern arises. V1 Administrator stated there are multiple residents who have multiple medical devices that are plugged into an extension cord due to that is the only option. V1 Administrator stated the facility does not have a policy for the use of medical devices plugged into an extension (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 4 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 02/11/2026 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)