Inspection Reports for The Hilltop at Blue River

The inspection was conducted due to a complaint alleging that Certified Medication Aide A forced Resident #2 to get out of bed against his/her will on 12/19/25.

The facility failed to maintain the dignity of one sampled resident when staff forced the resident to get out of bed against their will. The facility immediately provided education on residents' rights and corrected the deficiency on 12/20/25.

Complaint 2697434: The resident reported being forced out of bed by Certified Medication Aide A despite expressing refusal. Interviews with staff and the resident confirmed the incident. The facility was notified on 1/2/26 and took corrective action.

The inspection was conducted based on a complaint alleging the facility failed to ensure a resident's representative/power of attorney could exercise financial decision rights on behalf of the resident.

The facility failed to ensure that one sampled resident's representative was able to exercise financial decision-making rights. The investigation revealed issues with recognition and acceptance of the power of attorney, unauthorized changes to the resident's social security direct deposit, and communication problems between the facility and the resident's family.

The complaint investigation focused on Resident #3, whose representative/power of attorney was not allowed to exercise financial decision rights. The facility census was 145 residents. The investigation included interviews, record reviews, and emails showing family contact issues and facility actions regarding the resident's finances and POA status.

The inspection was conducted based on a complaint regarding failure to ensure safe smoking practices and supervision for residents, specifically concerning two sampled residents who had unsafe access to smoking materials and hazards during smoking breaks.

The facility failed to ensure one resident did not keep smoking materials in their room and smoked only in designated areas, and failed to provide adequate supervision and a safe environment during smoking breaks, including hazards such as wood with nails and broken equipment accessible in the smoking area. Multiple interviews and observations confirmed lapses in supervision and policy enforcement.

Complaint # MO 00250871 involved failure to ensure safe smoking practices and supervision for residents, including one resident keeping smoking materials in his/her room and smoking outside designated areas, and failure to maintain a safe smoking environment free of hazards.

The inspection was conducted to assess compliance with regulatory requirements including resident transfer/discharge notifications, bed hold agreements, activity programming, safety, nutrition, respiratory care, staffing, dental care, food service, and infection control.

The facility had multiple deficiencies including failure to provide timely and complete transfer/discharge notices and bed hold agreements; inadequate individualized activity plans for residents with dementia; unsafe environment and supervision during resident smoking breaks; failure to serve physician ordered diet texture and portion sizes; lack of nebulizer equipment and improper CPAP mask placement; insufficient weekend staffing; failure to provide dental care; poor food temperature control and seasoning; unclean kitchen equipment; and failure to implement enhanced barrier precautions for a resident with a wound and IV therapy.

The inspection was conducted due to a complaint or allegation regarding the facility's failure to obtain a physician order for self-administration of medication and failure to evaluate and document the ability of a resident to self-administer medication.

The facility failed to obtain a physician order and conduct an assessment for Resident #3 to self-administer medications at bedside. Medications were found stored in the resident's room without proper orders or assessments, and the resident had been self-administering extra doses of Tylenol and Melatonin without staff knowledge or authorization.

The complaint investigation revealed that Resident #3 had medications stored in his/her room without a physician's order or assessment for self-administration. Staff were unaware of the medications, and the resident had been self-administering extra doses. The facility policy requires assessments and physician orders for bedside medication storage, which were not followed.

The inspection was conducted following a complaint investigation related to a resident falling backwards in a wheelchair during transport due to the transportation driver not following proper wheelchair securing protocols.

The facility failed to ensure the transportation driver properly secured a resident's wheelchair, resulting in the resident falling backwards during transport. The resident sustained no acute injuries, and the facility provided immediate training and disciplinary action to the driver. The facility's policies require four straps to secure wheelchairs and seat belts for residents, but the driver used only three straps due to a missing strap.

The complaint investigation found that on 10/18/24, a resident fell backwards in his/her wheelchair during transport because the transportation driver used only three of the four required harness straps. The resident had no new injuries but later went to the emergency room for head, neck, and shoulder pain. The facility provided immediate training to the driver and implemented a checklist for transportation safety. The resident was cognitively intact and used a manual wheelchair. The incident was substantiated with minimal harm.

The inspection was conducted due to a complaint investigation regarding unaccounted controlled substances at the facility.

The facility failed to ensure controlled substances were properly counted during shift changes or key transfers, resulting in 60 tablets of Oxycodone 30 mg missing for one resident. The facility conducted an internal investigation, notified law enforcement and the DEA, and provided staff education on controlled substance counts.

The complaint investigation revealed that two cards of Oxycodone were missing from the medication cart. Staff failed to report missing medications timely to the Director of Nursing or Administrator. Law enforcement was contacted and staff were suspended pending investigation.

The inspection was conducted due to a complaint investigation regarding staff behavior and treatment of residents, specifically concerning the use of disrespectful profanity towards a resident.

The facility failed to ensure staff treated one sampled resident with dignity when two staff members used disrespectful profanity around the resident and other residents. Interviews confirmed the use of inappropriate language and acknowledged it as a dignity issue.

Complaint MO00220774. The Director of Nursing reported no concerns from residents related to staff profanity or disrespect.

The facility was investigated due to a complaint regarding staff disrespect and profanity towards a resident, as well as other concerns including care plan meetings, advanced directives, behavioral health care, restorative nursing, nutrition, infection control, medication management, and facility safety.

The facility was found to have multiple deficiencies including failure to treat residents with dignity, failure to conduct care plan meetings and notify residents/families, failure to offer and document advanced directives, failure to notify physicians of behavioral changes, failure to complete background checks prior to hire, failure to notify ombudsman of discharges, failure to provide activities tailored to residents' needs, failure to provide restorative nursing and apply splints, failure to monitor weights and notify physicians of weight loss, failure to provide adequate hydration, failure to coordinate dialysis care, failure to maintain infection control and antibiotic stewardship programs, failure to properly sanitize dietary areas, failure to ensure medication error rates below 5%, and failure to provide proper arbitration agreements.

Complaint MO00220774 regarding staff disrespect and profanity towards a resident.

The inspection was conducted due to complaints regarding resident-to-resident abuse incidents and concerns about medication administration and resident weight monitoring.

The facility failed to protect residents from abuse, with multiple incidents of resident-to-resident altercations resulting in injuries. Additionally, the facility failed to routinely obtain and document resident weights as ordered and failed to accurately document medication administration for a sampled resident. The facility also had issues with hot water availability and maintenance concerns in resident areas.

The complaint investigation was substantiated with findings of resident-to-resident abuse incidents involving Residents #1, #7, and #9, and failures in medication administration and weight monitoring.

The inspection was conducted due to a complaint investigation regarding the missing Oxycodone medication for Resident #7, which was delivered to unlicensed staff and subsequently unaccounted for.

The facility failed to ensure the safety of a sampled resident's controlled medication when the Oxycodone card was delivered to unlicensed staff and went missing. The medication was signed for by unlicensed personnel contrary to policy, and the medication was not properly secured. The facility replaced the missing medication and was working on re-education of staff regarding medication handling policies.

The investigation was triggered by the missing Oxycodone medication for Resident #7. The medication was signed for by a Certified Medication Technician (CMT C), who was not authorized to sign for controlled substances. The medication was left unsecured on the nurse's desk and subsequently went missing between 2:30 P.M. and 10:00 P.M. Police were called but no report was filed at the time. The facility replaced the medication and was working on staff re-education.

The inspection was conducted as part of the facility's annual survey to assess compliance with regulatory requirements including resident rights, activities, and medication management.

The facility was found deficient in obtaining proper consent for COVID-19 vaccinations, providing adequate activities to meet residents' needs, and ensuring proper medication labeling, storage, and cleanliness. Several residents were not provided with meaningful activities, and medication management issues included unlabeled opened medications, discontinued medications not removed, and unclean medication storage areas.