Cycle 1
Health 2021-06-16 · Fire 2021-06-16
4 health deficiencies
Top issue: Infection Control (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Ashland City, TN
Hillcrest Healthcare Center
4-star overall rating with 4-star inspections with 4 recent health deficiencies
111 E Pemberton Street, Ashland City, TN
(615) 792-9154
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
95
Certified beds
Average residents
71
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1993-11-20
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
0.30
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
1.43
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
2.26
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.99
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.73
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
3.61
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.16
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.29
CMS adjusted RN staffing hours
Adjusted total hours
3.94
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
6,993
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.10
Composite VBP score used to determine payment impact.
Payment multiplier
0.9863
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.57% · Performance 21.76% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.17
Baseline 5.78% · Performance 6.59% · Measure score 4.17 · Achievement 4.17 · Improvement 0
Total nurse turnover
7.56
Baseline 32.00% · Performance 32.79% · Measure score 7.56 · Achievement 7.56 · Improvement 0
Adjusted total nurse staffing
0.71
Baseline 3.14 hours · Performance 3.28 hours · Measure score 0.71 · Achievement 0.71 · Improvement 0.01
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.06% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 57 · Observed rate 12.28% · Lower 95% interval 7.53% |
| Discharge to community | 54.55% |
50.57%
4 pts better
|
No Different than the National Rate · Eligible stays 53 · Observed rate 49.06% · Lower 95% interval 41.86% |
| Medicare spending per beneficiary | 1.09 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 24 · Denominator 24 |
| Falls with major injury | 8.33% |
0.77%
7.6 pts worse
|
Numerator 2 · Denominator 24 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 4.17% |
2.29%
1.9 pts worse
|
Numerator 1 · Denominator 24 · Adjusted rate 3.53% |
| Healthcare-associated infections requiring hospitalization | 6.59% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 32 · Observed rate 3.13% · Lower 95% interval 3.62% |
| Staff COVID-19 vaccination coverage | 3.09% |
8.2%
5.1 pts worse
|
Numerator 3 · Denominator 97 |
| Staff flu vaccination coverage | 37.69% |
42%
4.3 pts worse
|
Numerator 49 · Denominator 130 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 12 · 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 | 2.0 |
1.6
0.4 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.5 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.1 |
1.6
1.5 pts worse
|
1.8
1.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.1 · Observed 2.2 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.5% |
89.9%
5.6 pts better
|
93.4%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.4% · Q2 98.3% · Q3 100.0% · Q4 86.2% · 4Q avg 95.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.5% |
94.5%
4 pts better
|
95.5%
3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.9% |
3.6%
1.3 pts worse
|
3.3%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 5.0% · Q3 6.6% · Q4 1.5% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
11.8%
11.8 pts better
|
11.4%
11.4 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 who lose too much weight | 7.6% |
6.2%
1.4 pts worse
|
5.4%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 6.7% · Q3 8.7% · Q4 6.2% · 4Q avg 7.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 29.5% |
32.2%
2.7 pts better
|
19.6%
9.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.9% · Q2 29.8% · Q3 31.2% · Q4 28.0% · 4Q avg 29.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.4% |
18.1%
4.3 pts worse
|
16.7%
5.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.4% · Q2 22.9% · Q3 24.3% · Q4 24.3% · 4Q avg 22.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 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 | 23.5% |
19.9%
3.6 pts worse
|
16.3%
7.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 23.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.3% |
15.3%
4 pts worse
|
14.9%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 20.0% · Q3 7.1% · Q4 37.8% · 4Q avg 19.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.9%
0.5 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
1.9%
1.1 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.3% |
20.2%
1.1 pts worse
|
19.8%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.3% · Q2 26.0% · Q3 14.9% · Q4 21.9% · 4Q avg 21.3% |
| Percentage of long-stay residents with pressure ulcers | 4.9% |
5.4%
0.5 pts better
|
5.1%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.5% · Q3 6.9% · Q4 7.6% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.5% |
79.6%
12.9 pts better
|
81.7%
10.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.2% · Q2 93.9% · Q3 95.4% · Q4 83.6% · 4Q avg 92.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.6% |
11.2%
0.4 pts worse
|
12.0%
0.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.6% · Observed 10.0% · Expected 9.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.7% |
1.6%
3.1 pts worse
|
1.6%
3.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 7.1% · Q3 2.9% · Q4 2.6% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.5% |
79.8%
15.7 pts better
|
79.7%
15.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.4% |
22.2%
2.2 pts worse
|
23.9%
0.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.4% · Observed 20.0% · Expected 19.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2019-05-21 · Fire 2019-05-21
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2018-08-15 · Fire 2018-08-15
0 health deficiencies
No concentrated health issue counts in this cycle.
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2018-08-15
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 2018-09-04
D · Potential for more than minimal harm
2018-08-15
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2018-09-04
D · Potential for more than minimal harm
2018-08-15
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2018-09-04
D · Potential for more than minimal harm
2018-08-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2018-09-07
D · Potential for more than minimal harm
2018-08-15
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2018-08-31
D · Potential for more than minimal harm
2018-08-15
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2018-09-15
D · Potential for more than minimal harm
2018-08-15
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2018-08-31
D · Potential for more than minimal harm
2018-08-15
K921 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure that testing and maintenance of electrical equipment is performed.
Corrected 2018-09-15
C · Minimal harm
2018-08-15
E15 · Emergency Preparedness Deficiencies
Fire Safety
Address subsistence needs for staff and patients.
Corrected 2018-09-07
Inspection history
Recent health citations
E · Potential for more than minimal harm
2021-06-16
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 2021-07-31
D · Potential for more than minimal harm
2021-06-16
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2021-07-02
D · Potential for more than minimal harm
2021-06-16
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2021-07-02
D · Potential for more than minimal harm
2021-06-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-07-31
D · Potential for more than minimal harm
2019-05-21
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2019-06-25
D · Potential for more than minimal harm
2019-05-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2019-06-25
D · Potential for more than minimal harm
2019-05-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2019-06-11
D · Potential for more than minimal harm
2019-05-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2019-06-14
D · Potential for more than minimal harm
2019-05-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2019-06-25
Penalties and ownership
What sits behind the stars
Ownership
Healthmark Services Inc
Operational/Managerial Control · Organization
Hightower, James
5% Or Greater Direct Ownership Interest · Individual
Hightower, James
Corporate Officer · Individual
Hightower, James
W-2 Managing Employee · Individual
Hightower, Patricia
5% Or Greater Direct Ownership Interest · Individual
Hightower, Patricia
Corporate Officer · Individual
Hightower, Patricia
W-2 Managing Employee · Individual
Hightower, Todd
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
The Waters Of Cheatham, LLC
Ashland City, TN
3-star overall rating with 2-star inspections with $6,350 in total fines with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Eaton Creek Post Acute
Nashville, TN
0-star overall rating with 0-star inspections with Special Focus status with $122,242 in total fines with 9 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
#3
Whites Creek Wellness And Rehabilitation Center
Whites Creek, TN
4-star overall rating with 4-star inspections with 3 recent health deficiencies
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