Hilltop Estates
2520 Avenue M, Gothenburg, NE 69138 · Dawson County · 64 certified beds · avg 41 residents/day · certified since Jul 2, 1995
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
All citations in the current public record (15)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jun 16, 2026 | F · Potential for harm, facility-wide | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| Jun 16, 2026 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jun 16, 2026 | E · Potential for harm, repeated | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. |
| Jun 16, 2026 | D · Potential for harm, one-off | The facility did not reassess a resident after a significant change in their condition, such as a sudden decline in health. A full new assessment is required when a resident's condition changes in a major way. |
| Jun 16, 2026 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Jun 16, 2026 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Jun 16, 2026 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Jun 16, 2026 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Mar 18, 2025 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Mar 18, 2025 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Mar 18, 2025 | D · Potential for harm, one-off | The facility did not provide necessary behavioral health care and services — support for residents' mental and emotional wellbeing, including conditions like depression and anxiety. |
| Mar 18, 2025 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Mar 21, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Mar 21, 2024 | F · Potential for harm, facility-wide | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Mar 21, 2024 | D · Potential for harm, one-off | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (4 → 8).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2024 | 3 | 0 | F |
| 2025 | 4 | 0 | F |
| 2026 | 8 | 0 | F |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Nebraska avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.61 | 4.33 | 3.95 | top 37% in Nebraska; top 20% in the U.S. |
| Registered Nurse hours | 0.82 | 0.72 | 0.69 | top 33% in Nebraska; top 26% in the U.S. |
| Weekend total nurse staffing | 3.80 | 3.79 | 3.50 | top 44% in Nebraska; top 29% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.50 | 0.47 | 0.48 | top 35% in Nebraska; top 32% in the U.S. |
| Total nursing staff turnover (%) | 46.4 | 48.7 | 45.8 | top 49% in Nebraska; bottom 46% in the U.S. |
| RN turnover (%) | 22.2 | 44.1 | 42.9 | top 23% in Nebraska; top 17% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.11, RN 0.73, weekend 3.38. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 3/5 · short-stay residents: 2/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Bartruff, Craig | Individual | 5% or Greater Direct Ownership Interest | — | 10/19/2009 |
| K C Health Care Enterprises INC | Organization | 5% or Greater Direct Ownership Interest | — | 02/15/1995 |
| Bahe, Scott | Individual | Corporate Officer | NOT APPLICABLE | 03/15/1998 |
| Bahe, Scott | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/15/1998 |
| Bahe, Scott | Individual | ADP of the SNF | NOT APPLICABLE | 03/15/1998 |
| Bartruff, Craig | Individual | Operational/Managerial Control | NOT APPLICABLE | 03/15/1995 |
| Bartruff, Craig | Individual | ADP of the SNF | NOT APPLICABLE | 03/15/1995 |
| Donner, Tiffany | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/11/2016 |
| Donner, Tiffany | Individual | ADP of the SNF | NOT APPLICABLE | 11/11/2016 |
| Family Physical Therapy & Sports Center | Organization | Operational/Managerial Control | NOT APPLICABLE | 12/01/2021 |
| Family Physical Therapy & Sports Center | Organization | ADP of the SNF | NOT APPLICABLE | 03/05/2025 |
| Flatwater Bank | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/01/1995 |
| Flatwater Bank | Organization | ADP of the SNF | NOT APPLICABLE | 03/05/2025 |
| K C Health Care Enterprises INC | Organization | ADP of the SNF | NOT APPLICABLE | 03/15/1995 |
| Key Rehabilitation INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 01/01/2024 |
| Key Rehabilitation INC | Organization | ADP of the SNF | NOT APPLICABLE | 02/24/2025 |
| Luminate HCC LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 12/01/2023 |
| Luminate HCC LLC | Organization | ADP of the SNF | NOT APPLICABLE | 02/21/2025 |
| Osborn, Shirley | Individual | Operational/Managerial Control | NOT APPLICABLE | 05/01/2019 |
| Osborn, Shirley | Individual | ADP of the SNF | NOT APPLICABLE | 05/01/2019 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Who reviews your menus, and can I see this week's menu and join my family member for a meal?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "How do you explain health changes and treatment options to residents and their families?"
- "If my family member's health suddenly changes, how quickly do you reassess them and update their care?"
- "Who completes resident assessments here, and how do you check them for accuracy?"
- "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
- "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Emerald Nursing & Rehab Cozad | 9.9 mi | Cozad, NE | ★☆☆☆☆ | 2/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 285163.