Cycle 1
Health 2025-01-09 · Fire 2025-01-09
2 health deficiencies
Top issue: Infection Control (1 deficiency)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (4 deficiencies)
Rutherfordton, NC
Hilltop Health and Rehabilitation
2-star overall rating with 2-star inspections with $25,812 in total fines with 2 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
188 Oscar Justice Road, Rutherfordton, NC
(828) 286-9001
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
80
Certified beds
Average residents
76
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Ascent Healthcare Management
Operator or chain grouping
Approved since
1972-12-13
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 2 overall / 2 health / 2 staffing / 2 quality stars
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
0.40
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.81
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.15
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.37
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.22
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
2.85
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.23
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.45
CMS adjusted RN staffing hours
Adjusted total hours
3.76
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,691
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.46
Composite VBP score used to determine payment impact.
Payment multiplier
0.9822
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.87
Baseline 21.30% · Performance 19.64% · Measure score 3.87 · Achievement 3.87 · Improvement 3.39
Healthcare-associated infections
0
Baseline 8.89% · Performance 8.82% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
2.26
Baseline 62.50% · Performance 54.43% · Measure score 2.26 · Achievement 2.26 · Improvement 1.64
Adjusted total nurse staffing
1.65
Baseline 3.44 hours · Performance 3.55 hours · Measure score 1.65 · Achievement 1.65 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.77% |
10.72%
1 pts better
|
No Different than the National Rate · Eligible stays 85 · Observed rate 7.06% · Lower 95% interval 6.7% |
| Discharge to community | 44.14% |
50.57%
6.4 pts worse
|
No Different than the National Rate · Eligible stays 74 · Observed rate 39.19% · Lower 95% interval 32.95% |
| Medicare spending per beneficiary | 1.06 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 54 · Denominator 54 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 54 |
| Discharge self-care score | 51.28% |
53.69%
2.4 pts worse
|
Numerator 20 · Denominator 39 |
| Discharge mobility score | 20.51% |
50.94%
30.4 pts worse
|
Numerator 8 · Denominator 39 |
| Pressure ulcers or injuries, new or worsened | 9.26% |
2.29%
7 pts worse
|
Numerator 5 · Denominator 54 · Adjusted rate 7.55% |
| Healthcare-associated infections requiring hospitalization | 8.82% |
7.12%
1.7 pts worse
|
No Different than the National Rate · Eligible stays 48 · Observed rate 12.5% · Lower 95% interval 5.01% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 91 |
| Staff flu vaccination coverage | 3.03% |
42%
39 pts worse
|
Numerator 4 · Denominator 132 |
| Discharge function score | 46.15% |
56.45%
10.3 pts worse
|
Numerator 18 · Denominator 39 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 95.24% |
96.28%
1 pts worse
|
Numerator 20 · Denominator 21 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 29 |
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 1.4 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.7 |
1.8
0.9 pts worse
|
1.8
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.4 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 75.8% |
91.5%
15.7 pts worse
|
93.4%
17.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 85.2% · Q2 72.1% · Q3 68.1% · Q4 79.2% · 4Q avg 75.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 80.8% |
94.1%
13.3 pts worse
|
95.5%
14.7 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 80.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.8% |
3.6%
1.2 pts worse
|
3.3%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 5.9% · Q3 4.2% · Q4 4.2% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.2% |
4.8%
3.6 pts better
|
11.4%
10.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.6% · Q4 2.9% · 4Q avg 1.2% |
| Percentage of long-stay residents who lose too much weight | 12.7% |
7.2%
5.5 pts worse
|
5.4%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 12.5% · Q3 13.8% · Q4 15.0% · 4Q avg 12.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 36.6% |
21.6%
15 pts worse
|
19.6%
17 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 33.3% · Q2 34.5% · Q3 36.2% · Q4 41.7% · 4Q avg 36.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.9% |
15.0%
3.9 pts worse
|
16.7%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.9% · Q2 18.4% · Q3 19.2% · Q4 17.5% · 4Q avg 18.9% · 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% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 10.8% |
21.5%
10.7 pts better
|
16.3%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 3.8% · Q4 0.0% · 4Q avg 10.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.7% |
16.8%
7.1 pts better
|
14.9%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.4% · Q2 10.9% · Q3 1.8% · Q4 5.3% · 4Q avg 9.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.9%
0.4 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.0% · Q3 1.1% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.7% |
2.6%
1.1 pts worse
|
1.7%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 4.4% · Q3 2.8% · Q4 5.6% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 30.4% |
21.2%
9.2 pts worse
|
19.8%
10.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.8% · Q2 32.7% · Q3 25.7% · Q4 26.1% · 4Q avg 30.4% |
| Percentage of long-stay residents with pressure ulcers | 7.7% |
6.0%
1.7 pts worse
|
5.1%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.6% · Q2 9.0% · Q3 6.4% · Q4 4.5% · 4Q avg 7.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 76.4% |
79.9%
3.5 pts worse
|
81.7%
5.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 65.8% · Q2 76.2% · Q3 84.2% · Q4 88.1% · 4Q avg 76.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 20.7% |
13.2%
7.5 pts worse
|
12.0%
8.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 20.7% · Observed 21.6% · Expected 11.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.9% |
1.5%
3.4 pts worse
|
1.6%
3.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 7.1% · Q3 0.0% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 73.0% |
78.1%
5.1 pts worse
|
79.7%
6.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 73.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.8% |
22.9%
3.1 pts better
|
23.9%
4.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.8% · Observed 18.9% · Expected 22.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-13 · Fire 2023-09-13
8 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
2 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Cycle 3
Health 2022-04-27 · Fire 2022-04-27
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
1 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
2025-01-09
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-05-07
F · Potential for more than minimal harm
2025-01-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-07
D · Potential for more than minimal harm
2025-01-09
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-05-07
D · Potential for more than minimal harm
2025-01-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-05-07
D · Potential for more than minimal harm
2025-01-09
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-05-07
D · Potential for more than minimal harm
2025-01-09
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-05-07
D · Potential for more than minimal harm
2025-01-09
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 2025-05-07
D · Potential for more than minimal harm
2025-01-09
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-05-07
D · Potential for more than minimal harm
2023-09-13
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-12-08
D · Potential for more than minimal harm
2023-09-13
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 2023-12-08
D · Potential for more than minimal harm
2022-04-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-06-08
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-01-09
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-01-22
D · Potential for more than minimal harm
2025-01-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-22
G · Actual harm
2023-09-13
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 2023-09-18
G · Actual harm
2023-09-13
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-09-18
E · Potential for more than minimal harm
2023-09-13
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-09-18
E · Potential for more than minimal harm
2023-09-13
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-09-18
E · Potential for more than minimal harm
2023-09-13
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 2023-09-18
E · Potential for more than minimal harm
2023-09-13
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 2023-09-18
D · Potential for more than minimal harm
2023-09-13
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-09-18
D · Potential for more than minimal harm
2023-09-13
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-18
K · Immediate jeopardy
2023-03-31
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-04-01
J · Immediate jeopardy
2023-03-31
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-04-01
D · Potential for more than minimal harm
2022-04-27
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-05-18
D · Potential for more than minimal harm
2022-04-27
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2022-05-18
Penalties and ownership
What sits behind the stars
$7,530
2023-09-13
Fine
Fine · fine $7,530
Fine
$18,282
2023-03-31
Fine
Fine · fine $18,282
Fine
Ownership
Friedman, Yisroel
5% Or Greater Indirect Ownership Interest · Individual
Pisgah Holdco LLC
5% Or Greater Direct Ownership Interest · Organization
Friedman, Yisroel
Operational/Managerial Control · Individual
Summerlin, Wesley
Operational/Managerial Control · Individual
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