Cycle 1
Health 2025-02-21 · Fire 2025-02-21
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Durham, NC
Hillcrest Convalescent Center
5-star overall rating with 5-star inspections with 2 fire-safety deficiencies in the latest cycle
1417 W Pettigrew Street, Durham, NC
(919) 286-7705
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
86
Certified beds
Average residents
78
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-01-01
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
1.25
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.88
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
3.43
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
5.55
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
2.13
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
5.11
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
1.04
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.37
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.32
CMS adjusted RN staffing hours
Adjusted total hours
5.87
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
6%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,115
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
59.72
Composite VBP score used to determine payment impact.
Payment multiplier
1.0149
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.33
Baseline 18.02% · Performance 19.42% · Measure score 4.33 · Achievement 4.33 · Improvement 0
Healthcare-associated infections
4.65
Baseline 5.64% · Performance 6.45% · Measure score 4.65 · Achievement 4.65 · Improvement 0
Total nurse turnover
4.91
Baseline 52.70% · Performance 43.61% · Measure score 4.91 · Achievement 4.91 · Improvement 2.77
Adjusted total nurse staffing
10
Baseline 6.60 hours · Performance 5.96 hours · Measure score 10 · Achievement 10 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.26% |
10.72%
2.5 pts better
|
Better than the National Rate · Eligible stays 835 · Observed rate 6.47% · Lower 95% interval 6.58% |
| Discharge to community | 72.94% |
50.57%
22.4 pts better
|
Better than the National Rate · Eligible stays 935 · Observed rate 68.34% · Lower 95% interval 69.35% |
| Medicare spending per beneficiary | 0.97 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.6% |
95.27%
2.3 pts better
|
Numerator 570 · Denominator 584 |
| Falls with major injury | 0.34% |
0.77%
0.4 pts better
|
Numerator 2 · Denominator 584 |
| Discharge self-care score | 51.99% |
53.69%
1.7 pts worse
|
Numerator 222 · Denominator 427 |
| Discharge mobility score | 52.93% |
50.94%
2 pts better
|
Numerator 226 · Denominator 427 |
| Pressure ulcers or injuries, new or worsened | 2.05% |
2.29%
0.2 pts better
|
Numerator 12 · Denominator 584 · Adjusted rate 2.2% |
| Healthcare-associated infections requiring hospitalization | 6.45% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 584 · Observed rate 5.82% · Lower 95% interval 4.93% |
| Staff COVID-19 vaccination coverage | 5.63% |
8.2%
2.6 pts worse
|
Numerator 18 · Denominator 320 |
| Staff flu vaccination coverage | 31.52% |
42%
10.5 pts worse
|
Numerator 145 · Denominator 460 |
| Discharge function score | 62.3% |
56.45%
5.8 pts better
|
Numerator 266 · Denominator 427 |
| Transfer of health information to provider | 96.5% |
95.95%
0.5 pts better
|
Numerator 138 · Denominator 143 |
| Transfer of health information to patient | 99.02% |
96.28%
2.7 pts better
|
Numerator 403 · Denominator 407 |
| Resident COVID-19 vaccinations up to date | 67.62% |
25.2%
42.4 pts better
|
Numerator 213 · Denominator 315 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.8
0.2 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 2.2 · Expected 2.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.2 |
1.8
1.6 pts better
|
1.8
1.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.2 · Observed 0.3 · Expected 2.1 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.4% |
91.5%
2.9 pts better
|
93.4%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 90.0% · Q2 90.5% · 4Q avg 94.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 85.7% |
94.1%
8.4 pts worse
|
95.5%
9.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 85.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.2% |
3.6%
0.6 pts worse
|
3.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 4.8% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.8%
4.8 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 13.4% |
7.2%
6.2 pts worse
|
5.4%
8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 10.0% · 4Q avg 13.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.0% |
21.6%
1.6 pts better
|
19.6%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 14.3% · 4Q avg 20.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 25.0% |
15.0%
10 pts worse
|
16.7%
8.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 25.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.0% |
16.8%
0.2 pts worse
|
14.9%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.2% |
0.9%
1.3 pts worse
|
1.0%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
2.6%
2.6 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 38.9% |
21.2%
17.7 pts worse
|
19.8%
19.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 38.9% |
| Percentage of long-stay residents with pressure ulcers | 20.3% |
6.0%
14.3 pts worse
|
5.1%
15.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 24.7% · 4Q avg 20.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.4% |
79.9%
18.5 pts better
|
81.7%
16.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.4% · Q2 98.4% · Q3 99.7% · Q4 98.7% · 4Q avg 98.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.6% |
13.2%
3.6 pts better
|
12.0%
2.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.6% · Observed 9.4% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.2% |
1.5%
0.7 pts worse
|
1.6%
0.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 2.7% · Q3 1.8% · Q4 1.5% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.4% |
78.1%
13.3 pts better
|
79.7%
11.7 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.2% |
22.9%
1.3 pts worse
|
23.9%
0.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.2% · Observed 23.0% · Expected 22.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-14 · Fire 2023-12-14
0 health deficiencies
No concentrated health issue counts in this cycle.
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2022-07-14 · Fire 2022-07-14
0 health deficiencies
No concentrated health issue counts in this cycle.
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-02-21
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 2025-03-21
D · Potential for more than minimal harm
2025-02-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-21
F · Potential for more than minimal harm
2023-12-14
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-02-23
F · Potential for more than minimal harm
2023-12-14
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-02-23
E · Potential for more than minimal harm
2023-12-14
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-02-23
D · Potential for more than minimal harm
2023-12-14
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2024-02-23
D · Potential for more than minimal harm
2023-12-14
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-02-23
D · Potential for more than minimal harm
2023-12-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-23
F · Potential for more than minimal harm
2022-07-14
K111 · Construction Deficiencies
Fire Safety
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Corrected 2022-09-18
F · Potential for more than minimal harm
2022-07-14
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-09-18
F · Potential for more than minimal harm
2022-07-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-09-18
F · Potential for more than minimal harm
2022-07-14
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-09-18
F · Potential for more than minimal harm
2022-07-14
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2022-09-18
D · Potential for more than minimal harm
2022-07-14
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-09-18
D · Potential for more than minimal harm
2022-07-14
K541 · Services Deficiencies
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2022-09-18
Inspection history
Recent health citations
Penalties and ownership
What sits behind the stars
Ownership
Smith, Lenwood
5% Or Greater Direct Ownership Interest · Individual
Smith, Thomas
5% Or Greater Direct Ownership Interest · Individual
Hoover, William
5% Or Greater Direct Ownership Interest · Individual
Tattersall, Crystal
5% Or Greater Direct Ownership Interest · Individual
Branch Banking & Trust Company
5% Or Greater Security Interest · Organization
Branch Banking & Trust Company
5% Or Greater Mortgage Interest · Organization
Fayer, Cynthia
Operational/Managerial Control · Individual
Hoover, Nadine
Corporate Director · Individual
Hoover, Nadine
Corporate Officer · Individual
Hoover, William
Operational/Managerial Control · Individual
Hoover, William
Corporate Officer · Individual
Shipley, Michael
Operational/Managerial Control · Individual
Smith, Lenwood
Corporate Officer · Individual
Smith, Thomas
Operational/Managerial Control · Individual
Smith, Thomas
Corporate Officer · Individual
Smith, Valerie
Operational/Managerial Control · Individual
Tattersall, Crystal
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Pettigrew Rehabilitation Center
Durham, NC
2-star overall rating with 3-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Durham Nursing & Rehabilitation Center
Durham, NC
2-star overall rating with 1-star inspections with $129,754 in total fines with 4 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Pruitthealth-Durham
Durham, NC
2-star overall rating with 2-star inspections with abuse icon flag with $30,303 in total fines with 10 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
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