Cycle 1
Health 2025-03-18 · Fire 2025-03-18
4 health deficiencies
Top issue: Infection Control (1 deficiency)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Gothenburg, NE
Hilltop Estates
4-star overall rating with 3-star inspections with 4 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
2520 Avenue M, Gothenburg, NE
(308) 537-7138
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
64
Certified beds
Average residents
40
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1995-07-02
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.79
Registered nurse staffing · state 0.71 · national 0.68
LPN hours / resident day
0.62
Licensed practical nurse staffing · state 0.71 · national 0.87
Aide hours / resident day
2.66
Nurse aide staffing · state 2.76 · national 2.35
Total nurse hours
4.07
All reported nurse hours · state 4.17 · national 3.89
Licensed hours
1.41
RN + LPN hours · state 1.41 · national 1.54
Weekend hours
3.58
Weekend nurse staffing · state 3.61 · national 3.43
Weekend RN hours
0.60
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.90
CMS adjusted RN staffing hours
Adjusted total hours
4.64
CMS adjusted total nurse staffing hours
Case-mix index
1.20
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,858
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.80
Composite VBP score used to determine payment impact.
Payment multiplier
0.9886
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.97
Performance 19.13% · Measure score 4.97 · Achievement 4.97 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
3.89
Baseline 6.42% · Performance 6.67% · Measure score 3.89 · Achievement 3.89 · Improvement 0
Total nurse turnover
2.31
Performance 54.24% · Measure score 2.31 · Achievement 2.31 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
2.75
Baseline 4.37 hours · Performance 3.86 hours · Measure score 2.75 · Achievement 2.75 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.25% |
10.72%
1.5 pts better
|
No Different than the National Rate · Eligible stays 75 · Observed rate 4% · Lower 95% interval 5.74% |
| Discharge to community | 35.06% |
50.57%
15.5 pts worse
|
Worse than the National Rate · Eligible stays 65 · Observed rate 29.23% · Lower 95% interval 25.61% |
| Medicare spending per beneficiary | 0.77 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 40 · Denominator 40 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 40 |
| Discharge self-care score | 47.06% |
53.69%
6.6 pts worse
|
Numerator 16 · Denominator 34 |
| Discharge mobility score | 44.12% |
50.94%
6.8 pts worse
|
Numerator 15 · Denominator 34 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 40 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.67% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 48 · Observed rate 4.17% · Lower 95% interval 3.12% |
| Staff COVID-19 vaccination coverage | 11.43% |
8.2%
3.2 pts better
|
Numerator 8 · Denominator 70 |
| Staff flu vaccination coverage | 13.11% |
42%
28.9 pts worse
|
Numerator 16 · Denominator 122 |
| Discharge function score | 47.06% |
56.45%
9.4 pts worse
|
Numerator 16 · Denominator 34 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
1.8
0.3 pts worse
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.0 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
2.0
0.8 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.2 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
92.8%
7.2 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
96.1%
3.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.7% |
4.5%
1.2 pts worse
|
3.3%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q2 2.3% · Q3 5.3% · Q4 10.8% · 4Q avg 5.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.7% |
4.4%
3.7 pts better
|
11.4%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.6% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% |
| Percentage of long-stay residents who lose too much weight | 0.8% |
5.3%
4.5 pts better
|
5.4%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.2% · 4Q avg 0.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.0% |
19.5%
0.5 pts better
|
19.6%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 19.4% · Q3 21.9% · Q4 18.2% · 4Q avg 19.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.6% |
21.6%
2 pts better
|
16.7%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 16.0% · Q3 21.7% · Q4 30.4% · 4Q avg 19.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.3%
0.3 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 9.0% |
20.4%
11.4 pts better
|
16.3%
7.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 3.6% · Q3 13.6% · Q4 3.2% · 4Q avg 9.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.2% |
19.9%
8.7 pts better
|
14.9%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 11.4% · Q3 12.5% · Q4 15.2% · 4Q avg 11.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.6%
1.6 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
2.9%
2.2 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.9% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.0% |
26.6%
5.6 pts better
|
19.8%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 26.4% · Q3 22.9% · Q4 18.9% · 4Q avg 21.0% |
| Percentage of long-stay residents with pressure ulcers | 5.0% |
4.3%
0.7 pts worse
|
5.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 7.5% · Q3 3.1% · Q4 6.0% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.6% |
80.5%
15.1 pts better
|
81.7%
13.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.5% · Q3 95.5% · Q4 96.6% · 4Q avg 95.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 0.0% |
11.6%
11.6 pts better
|
12.0%
12 pts better
|
Short Stay · 20240701-20250630 · Adjusted 0.0% · Observed 0.0% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
2.4%
2.4 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 14.4% |
20.9%
6.5 pts better
|
23.9%
9.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 14.4% · Observed 12.0% · Expected 19.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-21 · Fire 2024-03-21
3 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-02-15 · Fire 2023-02-15
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-18
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-04-01
F · Potential for more than minimal harm
2025-03-18
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-04-01
F · Potential for more than minimal harm
2025-03-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-01
F · Potential for more than minimal harm
2025-03-18
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-04-01
F · Potential for more than minimal harm
2025-03-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-01
E · Potential for more than minimal harm
2025-03-18
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-04-01
E · Potential for more than minimal harm
2025-03-18
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-04-01
D · Potential for more than minimal harm
2024-03-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-03-21
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-04-12
F · Potential for more than minimal harm
2023-02-15
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-04-01
D · Potential for more than minimal harm
2023-02-15
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-04-01
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-03-18
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-04-03
F · Potential for more than minimal harm
2025-03-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-03
D · Potential for more than minimal harm
2025-03-18
F740 · Quality of Life and Care Deficiencies
Health
Ensure each resident must receive and the facility must provide necessary behavioral health care and services.
Corrected 2025-04-03
D · Potential for more than minimal harm
2025-03-18
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-04-03
F · Potential for more than minimal harm
2024-03-21
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-04-12
F · Potential for more than minimal harm
2024-03-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-03-21
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-04-12
Penalties and ownership
What sits behind the stars
Ownership
Bahe, Scott
Operational/Managerial Control · Individual
Bahe, Scott
Corporate Officer · Individual
Bartruff, Craig
5% Or Greater Direct Ownership Interest · Individual
Bartruff, Craig
Operational/Managerial Control · Individual
Donner, Tiffany
Operational/Managerial Control · Individual
Family Physical Therapy & Sports Center
Operational/Managerial Control · Organization
Flatwater Bank
Operational/Managerial Control · Organization
K C Health Care Enterprises Inc
5% Or Greater Direct Ownership Interest · Organization
Key Rehabilitation,inc
Operational/Managerial Control · Organization
Luminate Hcc LLC
Operational/Managerial Control · Organization
Osborn, Shirley
Operational/Managerial Control · Individual
S. Douglas Kucera, Cpa
Operational/Managerial Control · Organization
Stoddard, Emily
Operational/Managerial Control · Individual
Weicker, Rachel
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Emerald Nursing & Rehab Cozad
Cozad, NE
1-star overall rating with 2-star inspections with 6 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Callaway Good Life Center, Inc
Callaway, NE
2-star overall rating with 2-star inspections with $34,608 in total fines with 11 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Elwood Care Center
Elwood, NE
5-star overall rating with 5-star inspections with 2 fire-safety deficiencies in the latest cycle
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