Cycle 1
Health 2025-05-02 · Fire 2025-05-02
12 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Duluth, MN
Hilltop Healthcare Rehabilitation And Skilled Nurs
1-star overall rating with 2-star inspections with $244,730 in total fines with 12 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
2501 Rice Lake Road, Duluth, MN
(218) 625-6421
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
140
Certified beds
Average residents
103
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1986-08-01
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
0.94
Registered nurse staffing · state 1.06 · national 0.68
LPN hours / resident day
0.52
Licensed practical nurse staffing · state 0.62 · national 0.87
Aide hours / resident day
2.24
Nurse aide staffing · state 2.56 · national 2.35
Total nurse hours
3.70
All reported nurse hours · state 4.23 · national 3.89
Licensed hours
1.46
RN + LPN hours · state 1.68 · national 1.54
Weekend hours
3.22
Weekend nurse staffing · state 3.68 · national 3.43
Weekend RN hours
0.63
Weekend registered nurse coverage · state 0.68 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
1.09
CMS adjusted RN staffing hours
Adjusted total hours
4.27
CMS adjusted total nurse staffing hours
Case-mix index
1.19
Higher values indicate more complex resident acuity
RN turnover
61%
Annual RN turnover · state 39% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 42% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,243
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
7.25
Composite VBP score used to determine payment impact.
Payment multiplier
0.9807
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.13% · Performance 22.47% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 5.29% · Performance 8.12% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0.69
Baseline 65.12% · Performance 60.87% · Measure score 0.69 · Achievement 0.69 · Improvement 0.55
Adjusted total nurse staffing
2.21
Baseline 3.66 hours · Performance 3.71 hours · Measure score 2.21 · Achievement 2.21 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.63% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 92 · Observed rate 8.7% · Lower 95% interval 6.31% |
| Discharge to community | 41.19% |
50.57%
9.4 pts worse
|
No Different than the National Rate · Eligible stays 74 · Observed rate 32.43% · Lower 95% interval 31.7% |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.12% |
95.27%
1.9 pts better
|
Numerator 101 · Denominator 104 |
| Falls with major injury | 3.85% |
0.77%
3.1 pts worse
|
Numerator 4 · Denominator 104 |
| Discharge self-care score | 34.21% |
53.69%
19.5 pts worse
|
Numerator 26 · Denominator 76 |
| Discharge mobility score | 22.37% |
50.94%
28.6 pts worse
|
Numerator 17 · Denominator 76 |
| Pressure ulcers or injuries, new or worsened | 0.96% |
2.29%
1.3 pts better
|
Numerator 1 · Denominator 104 · Adjusted rate 1.08% |
| Healthcare-associated infections requiring hospitalization | 8.12% |
7.12%
1 pts worse
|
No Different than the National Rate · Eligible stays 55 · Observed rate 12.73% · Lower 95% interval 5.13% |
| Staff COVID-19 vaccination coverage | 10.55% |
8.2%
2.4 pts better
|
Numerator 21 · Denominator 199 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 39.47% |
56.45%
17 pts worse
|
Numerator 30 · Denominator 76 |
| Transfer of health information to provider | 88% |
95.95%
8 pts worse
|
Numerator 22 · Denominator 25 |
| Transfer of health information to patient | 92.86% |
96.28%
3.4 pts worse
|
Numerator 26 · Denominator 28 |
| Resident COVID-19 vaccinations up to date | 52% |
25.2%
26.8 pts better
|
Numerator 26 · Denominator 50 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.7
0.1 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 2.7 · Expected 3.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.0 |
2.0
2 pts worse
|
1.8
2.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.0 · Observed 6.4 · Expected 2.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
97.3%
1.7 pts better
|
93.4%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 95.9% · Q3 100.0% · Q4 100.0% · 4Q avg 99.0% |
| 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 | 4.4% |
3.9%
0.5 pts worse
|
3.3%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 7.1% · Q3 5.3% · Q4 0.0% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 12.6% |
4.3%
8.3 pts worse
|
11.4%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 13.0% · Q3 16.5% · Q4 10.4% · 4Q avg 12.6% |
| Percentage of long-stay residents who lose too much weight | 3.5% |
4.1%
0.6 pts better
|
5.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 6.2% · Q3 5.3% · Q4 1.3% · 4Q avg 3.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.5% |
12.4%
3.1 pts worse
|
19.6%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 15.5% · Q3 15.2% · Q4 13.3% · 4Q avg 15.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.7% |
17.5%
5.2 pts worse
|
16.7%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.2% · Q2 27.7% · Q3 23.4% · Q4 16.9% · 4Q avg 22.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 2.1% |
0.1%
2 pts worse
|
0.1%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.0% · Q3 2.1% · Q4 2.1% · 4Q avg 2.1% |
| Percentage of long-stay residents whose ability to walk independently worsened | 29.5% |
22.5%
7 pts worse
|
16.3%
13.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.6% · Q2 43.0% · Q3 27.2% · Q4 17.3% · 4Q avg 29.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.3% |
18.6%
0.3 pts better
|
14.9%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.7% · Q2 26.9% · Q3 12.2% · Q4 11.1% · 4Q avg 18.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.7% |
2.3%
0.4 pts worse
|
1.0%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 3.7% · Q3 2.3% · Q4 1.1% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.6% |
2.6%
2 pts worse
|
1.7%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 3.2% · Q3 10.0% · Q4 3.1% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.0% |
24.8%
1.8 pts better
|
19.8%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.1% · Q2 26.8% · Q3 22.5% · Q4 15.3% · 4Q avg 23.0% |
| Percentage of long-stay residents with pressure ulcers | 6.6% |
5.4%
1.2 pts worse
|
5.1%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 7.6% · Q3 5.3% · Q4 7.5% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 85.5% |
88.6%
3.1 pts worse
|
81.7%
3.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 86.2% · Q2 79.2% · Q3 88.6% · Q4 88.2% · 4Q avg 85.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.1% |
14.0%
3.1 pts worse
|
12.0%
5.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.1% · Observed 20.3% · Expected 13.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.7% |
1.9%
1.8 pts worse
|
1.6%
2.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 4.9% · Q3 5.3% · Q4 2.6% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 84.8% |
82.7%
2.1 pts better
|
79.7%
5.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 84.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.9% |
23.1%
3.2 pts better
|
23.9%
4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.9% · Observed 21.9% · Expected 26.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-16 · Fire 2024-02-16
12 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2023-06-12 · Fire 2023-06-12
24 health deficiencies
Top issue: Resident Rights (8 deficiencies)
15 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-05-02
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2025-05-19
F · Potential for more than minimal harm
2025-05-02
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-05-19
F · Potential for more than minimal harm
2025-05-02
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-05-19
F · Potential for more than minimal harm
2025-05-02
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-05-19
F · Potential for more than minimal harm
2025-05-02
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-05-19
F · Potential for more than minimal harm
2025-05-02
K901 · Electrical Deficiencies
Fire Safety
Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel.
Corrected 2025-05-19
F · Potential for more than minimal harm
2025-05-02
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 2025-05-19
F · Potential for more than minimal harm
2025-05-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-19
F · Potential for more than minimal harm
2025-05-02
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-05-19
D · Potential for more than minimal harm
2025-05-02
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2025-05-19
D · Potential for more than minimal harm
2025-05-02
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-05-19
D · Potential for more than minimal harm
2025-05-02
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2025-05-19
F · Potential for more than minimal harm
2024-02-16
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2024-04-03
F · Potential for more than minimal harm
2024-02-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-03
F · Potential for more than minimal harm
2024-02-16
K354 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.
Corrected 2024-04-03
F · Potential for more than minimal harm
2024-02-16
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-04-03
F · Potential for more than minimal harm
2024-02-16
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-04-03
F · Potential for more than minimal harm
2024-02-16
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-03-04
E · Potential for more than minimal harm
2024-02-16
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-04-03
D · Potential for more than minimal harm
2024-02-16
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-02-16
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-02-16
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-02-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-03-04
F · Potential for more than minimal harm
2023-06-12
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-08-17
F · Potential for more than minimal harm
2023-06-12
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-08-17
F · Potential for more than minimal harm
2023-06-12
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-07-21
F · Potential for more than minimal harm
2023-06-12
K711 · Miscellaneous Deficiencies
Fire Safety
Provide a written emergency evacuation plan.
Corrected 2023-07-21
F · Potential for more than minimal harm
2023-06-12
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-07-21
F · Potential for more than minimal harm
2023-06-12
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-07-21
F · Potential for more than minimal harm
2023-06-12
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 2023-07-21
F · Potential for more than minimal harm
2023-06-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-07-21
E · Potential for more than minimal harm
2023-06-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-17
D · Potential for more than minimal harm
2023-06-12
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-07-21
D · Potential for more than minimal harm
2023-06-12
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-07-21
D · Potential for more than minimal harm
2023-06-12
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-07-21
C · Minimal harm
2023-06-12
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-07-26
C · Minimal harm
2023-06-12
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-07-24
C · Minimal harm
2023-06-12
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2023-07-21
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-05-02
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2025-05-20
D · Potential for more than minimal harm
2025-05-02
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-05-20
D · Potential for more than minimal harm
2025-05-02
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-05-20
D · Potential for more than minimal harm
2025-05-02
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-05-20
D · Potential for more than minimal harm
2025-05-02
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-05-20
D · Potential for more than minimal harm
2025-05-02
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-05-20
D · Potential for more than minimal harm
2025-05-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-05-20
D · Potential for more than minimal harm
2025-05-02
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-05-20
D · Potential for more than minimal harm
2025-05-02
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-05-20
D · Potential for more than minimal harm
2025-05-02
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-05-20
D · Potential for more than minimal harm
2025-05-02
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 2025-05-20
G · Actual harm
2025-03-13
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 2025-03-06
J · Immediate jeopardy
2025-01-17
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2025-01-15
J · Immediate jeopardy
2024-09-05
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 2024-09-27
D · Potential for more than minimal harm
2024-09-05
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2024-09-27
C · Minimal harm
2024-09-05
F944 · Administration Deficiencies
Health
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Corrected 2024-09-27
E · Potential for more than minimal harm
2024-02-16
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-03-15
E · Potential for more than minimal harm
2024-02-16
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 2024-03-15
E · Potential for more than minimal harm
2024-02-16
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 2024-03-15
E · Potential for more than minimal harm
2024-02-16
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-16
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-03-18
D · Potential for more than minimal harm
2024-02-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-15
D · Potential for more than minimal harm
2024-02-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-03-15
C · Minimal harm
2024-02-16
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2024-03-15
D · Potential for more than minimal harm
2023-11-22
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2023-12-27
F · Potential for more than minimal harm
2023-06-12
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2023-07-16
E · Potential for more than minimal harm
2023-06-12
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2023-07-26
E · Potential for more than minimal harm
2023-06-12
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-07-24
D · Potential for more than minimal harm
2023-06-12
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-07-24
D · Potential for more than minimal harm
2023-06-12
F557 · Resident Rights Deficiencies
Health
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected 2023-07-24
D · Potential for more than minimal harm
2023-06-12
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-07-24
D · Potential for more than minimal harm
2023-06-12
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-07-24
D · Potential for more than minimal harm
2023-06-12
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-07-24
D · Potential for more than minimal harm
2023-06-12
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-07-24
D · Potential for more than minimal harm
2023-06-12
F659 · Resident Assessment and Care Planning Deficiencies
Health
Provide care by qualified persons according to each resident's written plan of care.
Corrected 2023-07-24
D · Potential for more than minimal harm
2023-06-12
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-07-24
D · Potential for more than minimal harm
2023-06-12
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-07-24
D · Potential for more than minimal harm
2023-06-12
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-24
D · Potential for more than minimal harm
2023-06-12
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 2023-07-24
D · Potential for more than minimal harm
2023-06-12
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-07-24
D · Potential for more than minimal harm
2023-06-12
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-07-26
D · Potential for more than minimal harm
2023-06-12
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-07-24
D · Potential for more than minimal harm
2023-06-12
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-07-26
D · Potential for more than minimal harm
2023-06-12
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-07-24
D · Potential for more than minimal harm
2023-06-12
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 2023-07-26
D · Potential for more than minimal harm
2023-06-12
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2023-07-26
D · Potential for more than minimal harm
2023-06-12
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 2023-07-24
D · Potential for more than minimal harm
2023-06-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-24
Penalties and ownership
What sits behind the stars
$22,315
2025-03-13
Fine
Fine · fine $22,315
Fine
$26,130
2025-01-17
Fine
Fine · fine $26,130
Fine
$196,285
2024-09-05
Fine
Fine · fine $196,285
Fine
Ownership
Halpert, Ephraim
5% Or Greater Direct Ownership Interest · Individual
Frey-Tykward, Lisa
Operational/Managerial Control · Individual
Friedman, Steven
Operational/Managerial Control · Individual
Halpert, Ephraim
Corporate Officer · Individual
Peterson, Gary
Operational/Managerial Control · Individual
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1-star overall rating with 1-star inspections with abuse icon flag with 12 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
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Aftenro Home
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4-star overall rating with 3-star inspections with 6 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Viewcrest Health Center
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3-star overall rating with 3-star inspections with $60,781 in total fines with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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