Cycle 1
Health 2024-12-05 · Fire 2024-12-05
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Union, MS
Hilltop Manor Health And Rehabilitation Center
4-star overall rating with 3-star inspections with 7 recent health deficiencies
101 Kirkland Street, Union, MS
(601) 774-8233
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
53
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Consulate Health Care/Independence Living Centers/Nspire Healthcare/Raydiant Health Care
Operator or chain grouping
Approved since
2000-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
36 facilities
Chain averages 2 overall / 2 health / 3 staffing / 3 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
1.35
Registered nurse staffing · state 0.63 · national 0.68
LPN hours / resident day
0.40
Licensed practical nurse staffing · state 1.10 · national 0.87
Aide hours / resident day
1.86
Nurse aide staffing · state 2.48 · national 2.35
Total nurse hours
3.60
All reported nurse hours · state 4.21 · national 3.89
Licensed hours
1.75
RN + LPN hours · state 1.73 · national 1.54
Weekend hours
3.07
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.86
Weekend registered nurse coverage · state 0.37 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
1.52
CMS adjusted RN staffing hours
Adjusted total hours
4.08
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
7%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
43%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,766
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
22.61
Composite VBP score used to determine payment impact.
Payment multiplier
0.9829
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.67% · Performance 22.57% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.10
Baseline 6.37% · Performance 7.51% · Measure score 1.10 · Achievement 1.10 · Improvement 0
Total nurse turnover
3.15
Baseline 61.19% · Performance 50.82% · Measure score 3.15 · Achievement 3.15 · Improvement 2.35
Adjusted total nurse staffing
4.80
Baseline 4.42 hours · Performance 4.44 hours · Measure score 4.80 · Achievement 4.80 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.72% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 39 · Observed rate 12.82% · Lower 95% interval 7.03% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 18 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.9 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 94.81% |
95.27%
0.5 pts worse
|
Numerator 73 · Denominator 77 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 77 |
| Discharge self-care score | 48.89% |
53.69%
4.8 pts worse
|
Numerator 22 · Denominator 45 |
| Discharge mobility score | 28.89% |
50.94%
22 pts worse
|
Numerator 13 · Denominator 45 |
| Pressure ulcers or injuries, new or worsened | 2.6% |
2.29%
0.3 pts worse
|
Numerator 2 · Denominator 77 · Adjusted rate 2.11% |
| Healthcare-associated infections requiring hospitalization | 7.51% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 32 · Observed rate 9.38% · Lower 95% interval 3.85% |
| Staff COVID-19 vaccination coverage | 6.52% |
8.2%
1.7 pts worse
|
Numerator 3 · Denominator 46 |
| Staff flu vaccination coverage | 28.79% |
42%
13.2 pts worse
|
Numerator 19 · Denominator 66 |
| Discharge function score | 46.67% |
56.45%
9.8 pts worse
|
Numerator 21 · Denominator 45 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 27 · Denominator 27 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 51.43% |
25.2%
26.2 pts better
|
Numerator 18 · Denominator 35 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.4 |
2.4
1 pts worse
|
1.9
1.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.4 · Observed 2.9 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.0 |
2.9
1.1 pts worse
|
1.8
2.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.0 · Observed 3.7 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
95.7%
3.8 pts better
|
93.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.1% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.0%
3 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 | 2.5% |
3.2%
0.7 pts better
|
3.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 3.8% · Q3 0.0% · Q4 2.2% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.6% |
1.6%
1 pts better
|
11.4%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% |
| Percentage of long-stay residents who lose too much weight | 1.7% |
6.1%
4.4 pts better
|
5.4%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.3% · Q4 2.5% · 4Q avg 1.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.3% |
24.4%
2.9 pts worse
|
19.6%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.4% · Q2 21.7% · Q3 27.7% · Q4 27.9% · 4Q avg 27.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.6% |
23.4%
12.8 pts better
|
16.7%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.5% · Q2 10.0% · Q3 9.5% · Q4 13.5% · 4Q avg 10.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 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 | 24.6% |
22.8%
1.8 pts worse
|
16.3%
8.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.4% · 4Q avg 24.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.3% |
20.6%
2.7 pts worse
|
14.9%
8.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.3% · Q2 15.0% · Q3 26.8% · Q4 23.7% · 4Q avg 23.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.9% |
1.5%
0.4 pts worse
|
1.0%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 2.3% · Q3 1.9% · Q4 2.1% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
2.5%
0.9 pts better
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 2.2% · Q3 2.0% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.3% |
21.4%
9.9 pts worse
|
19.8%
11.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.7% · Q2 43.2% · Q3 28.0% · Q4 37.7% · 4Q avg 31.3% |
| Percentage of long-stay residents with pressure ulcers | 4.1% |
6.9%
2.8 pts better
|
5.1%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 4.0% · Q3 3.5% · Q4 2.1% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
87.9%
11.5 pts better
|
81.7%
17.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 97.9% · 4Q avg 99.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 22.1% |
15.3%
6.8 pts worse
|
12.0%
10.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 22.1% · Observed 26.8% · Expected 13.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.0% |
2.6%
0.4 pts worse
|
1.6%
1.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 0.0% · Q3 0.0% · Q4 7.4% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.5% |
84.6%
12.9 pts better
|
79.7%
17.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 26.4% |
27.9%
1.5 pts better
|
23.9%
2.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 26.4% · Observed 30.4% · Expected 27.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-03 · Fire 2023-08-03
11 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-01-06 · Fire 2022-01-06
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2023-08-03
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-09-25
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-12-05
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-01-06
D · Potential for more than minimal harm
2024-12-05
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2025-01-06
D · Potential for more than minimal harm
2024-12-05
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-01-06
D · Potential for more than minimal harm
2024-12-05
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2025-01-06
D · Potential for more than minimal harm
2024-12-05
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-01-06
D · Potential for more than minimal harm
2024-12-05
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 2025-01-06
D · Potential for more than minimal harm
2024-12-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-06
F · Potential for more than minimal harm
2023-08-03
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-09-14
E · Potential for more than minimal harm
2023-08-03
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-09-14
E · Potential for more than minimal harm
2023-08-03
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-09-14
D · Potential for more than minimal harm
2023-08-03
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-09-14
D · Potential for more than minimal harm
2023-08-03
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 2023-09-14
D · Potential for more than minimal harm
2023-08-03
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-09-14
D · Potential for more than minimal harm
2023-08-03
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 2023-09-14
D · Potential for more than minimal harm
2023-08-03
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 2023-09-14
D · Potential for more than minimal harm
2023-08-03
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-09-14
D · Potential for more than minimal harm
2023-08-03
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-09-14
D · Potential for more than minimal harm
2023-08-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-14
F · Potential for more than minimal harm
2022-01-06
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 2022-03-06
F · Potential for more than minimal harm
2022-01-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-03-06
E · Potential for more than minimal harm
2022-01-06
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2022-03-06
D · Potential for more than minimal harm
2022-01-06
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 2022-03-06
D · Potential for more than minimal harm
2022-01-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-03-06
D · Potential for more than minimal harm
2022-01-06
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2022-03-06
Penalties and ownership
What sits behind the stars
Ownership
Fc Encore Union LLC
5% Or Greater Security Interest · Organization
Hoback, Tiffany
Operational/Managerial Control · Individual
Jones, Tequilla
Operational/Managerial Control · Individual
Perry, William
Operational/Managerial Control · Individual
Smith, Alex
Operational/Managerial Control · Individual
Snf Mgr LLC
Operational/Managerial Control · Organization
Tate, Crystal
Operational/Managerial Control · Individual
Thomas, John
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
J G Alexander Nursing Center
Union, MS
1-star overall rating with 2-star inspections with $16,720 in total fines with 9 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Neshoba County Nursing Home
Philadelphia, MS
2-star overall rating with 2-star inspections with 9 recent health deficiencies
#3
Choctaw Residential Center
Choctaw, MS
2-star overall rating with 3-star inspections with $21,165 in total fines with 10 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
Jump out
Supporting pages
City page
Best nursing homes in Union, MS
See how this facility ranks inside its city.
2 facilitiesCounty
Neshoba County
County ranking page for nearby alternatives.
3 facilitiesChain
Consulate Health Care/Independence Living Centers/Nspire Healthcare/Raydiant Health Care
Chain page for the operating group.
36 facilities