Map showing the location of HILLTOP HEALTHCARE REHABILITATION AND SKILLED NURS in DULUTH, Minnesota
2501 RICE LAKE ROAD, DULUTH, MN, 55811

Overall Score

CMS Five-Star Quality Rating
1/5Much below averageCMS Five-Star overall rating
  1. Much below average
  2. Below average
  3. Average
  4. Above average
  5. Much above average

Where it ranks

  • MinnesotaLowest tier among peers337 rated homes · average 3.2★
  • St. Louis CountyLowest tier among peers17 rated homes · average 2.7★
  • United StatesLowest tier among peers14,574 rated homes · average 3.0★

How the rating is built

  • Health inspectionsStarting point2★−0.8 vs MN avg
  • StaffingCan add or remove a star4★−0.1 vs MN avg
  • Quality measuresCan add or remove a star1★−2.2 vs MN avg

CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.

Ratings & measures

Tap a row to see what it means
Health inspection ratingCMS stars from the last three on-site inspection cycles2★Above only 19% of peersMN avg2.8★U.S. avg2.8★
What is health inspection rating?

Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.

Why it matters

It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.

Staffing ratingCMS stars from payroll-reported hours and turnover4★Above only 22% of peersMN avg4.1★U.S. avg2.9★
What is staffing rating?

Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.

Why it matters

More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.

Quality measures ratingCMS stars from clinical outcomes and resident assessments1★Lowest tier among peersMN avg3.2★U.S. avg3.6★
What is quality measures rating?

Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.

Why it matters

It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.

Total nurse hoursPer resident per day, all nursing staff3.70hrsAbove only 23% of peersMN avg4.23Benchmark4.10
What is total nurse hours?

All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.

Why it matters

Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.

RN hoursPer resident per day, registered nurses only0.94hrsAbove only 48% of peersMN avg1.06Benchmark0.75
What is rn hours?

Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.

Why it matters

RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.

Nursing staff turnoverShare of nursing staff who left within a year · lower is better51%Above only 26% of peersMN avg42%RN turnover61%
What is nursing staff turnover?

The share of nursing staff who left within the past year, from the same payroll data.

Why it matters

High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.

Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$244,730Lowest tier among peersMN avg$19,953Fines · denials3 · 0
What is fines in the last three years?

Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.

Why it matters

Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.

Inspection history

Last three inspection cycles
48citations
7inspection dates
1actual harm (G–I)
2immediate jeopardy (J–L)
May 2, 2025most recent

Citations by monthJun 2023 – May 2025

  • No actual harm (D–F)
  • Actual harm (G–I)
  • Immediate jeopardy (J–L)
  • $Fine or payment denial

Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.

May 2, 202511 citationsCycle 1worst F · no actual harm
  1. F761Ensure 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.Pharmacy ServiceD · isolatedCorrected May 20, 2025
  2. F645PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care PlanningD · isolatedCorrected May 20, 2025
  3. F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningD · isolatedCorrected May 20, 2025
  4. F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningD · isolatedCorrected May 20, 2025
  5. F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Quality of Life and CareD · isolatedCorrected May 20, 2025
  6. F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Nursing and Physician ServicesD · isolatedCorrected May 20, 2025
  7. 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.Nutrition and DietaryF · widespreadCorrected May 20, 2025
  8. Ensure each resident’s drug regimen must be free from unnecessary drugs.Pharmacy ServiceD · isolatedCorrected May 20, 2025
  9. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected May 20, 2025
  10. F605Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected May 20, 2025
  11. F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected May 20, 2025
Mar 13, 20251 citationCycle 1worst G · actual harm$22,315
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Mar 6, 2025
Jan 17, 20251 citationCycle 2worst J · immediate jeopardy$26,130
  1. Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.Quality of Life and CareJ · isolatedCorrected Jan 15, 2025
Sep 5, 20243 citationsCycle 2worst J · immediate jeopardy$196,285
  1. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareJ · isolatedCorrected Sep 27, 2024
  2. F947Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.Nursing and Physician ServicesD · isolatedCorrected Sep 27, 2024
  3. Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.AdministrationC · widespreadCorrected Sep 27, 2024
Feb 16, 20248 citationsCycle 2worst E · no actual harm
  1. F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection ControlE · patternCorrected Mar 15, 2024
  2. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Mar 15, 2024
  3. F577Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.Resident RightsC · widespreadCorrected Mar 15, 2024
  4. F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected Mar 18, 2024
  5. F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningE · patternCorrected Mar 15, 2024
  6. F761Ensure 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.Pharmacy ServiceE · patternCorrected Mar 15, 2024
  7. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Mar 15, 2024
  8. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Mar 15, 2024
Nov 22, 20231 citationCycle 3worst D · no actual harm
  1. F622Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.Resident RightsD · isolatedCorrected Dec 27, 2023
Jun 12, 202323 citationsCycle 3worst F · no actual harm
  1. F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Jul 24, 2023
  2. F554Allow residents to self-administer drugs if determined clinically appropriate.Resident RightsD · isolatedCorrected Jul 24, 2023
  3. F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Jul 24, 2023
  4. F567Honor the resident's right to manage his or her financial affairs.Resident RightsE · patternCorrected Jul 26, 2023
  5. F578Honor 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.Resident RightsD · isolatedCorrected Jul 24, 2023
  6. F583Keep residents' personal and medical records private and confidential.Resident RightsD · isolatedCorrected Jul 24, 2023
  7. F585Honor 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.Resident RightsD · isolatedCorrected Jul 24, 2023
  8. F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningE · patternCorrected Jul 24, 2023
  9. F282Provide care by qualified persons according to each resident's written plan of care.Resident Assessment and Care PlanningD · isolatedCorrected Jul 24, 2023
  10. F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Jul 24, 2023
  11. F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Jul 24, 2023
  12. F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Jul 26, 2023
  13. F758Implement 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.Pharmacy ServiceD · isolatedCorrected Jul 26, 2023
  14. F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected Jul 24, 2023
  15. F761Ensure 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.Pharmacy ServiceD · isolatedCorrected Jul 26, 2023
  16. F806Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.Nutrition and DietaryD · isolatedCorrected Jul 26, 2023
  17. F882Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.Infection ControlF · widespreadCorrected Jul 16, 2023
  18. F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryD · isolatedCorrected Jul 24, 2023
  19. F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Jul 24, 2023
  20. F557Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.Resident RightsD · isolatedCorrected Jul 24, 2023
  21. F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Jul 24, 2023
  22. Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and CareD · isolatedCorrected Jul 24, 2023
  23. F686Provide appropriate pressure ulcer care and prevent new ulcers from developing.Quality of Life and CareD · isolatedCorrected Jul 24, 2023

Staffing

From quarterly payroll reports

Hours per resident per day

  • All nursing staffRNs, LPNs and aides combined3.70hrsAbove only 23% of peers−0.53 vs MN avg
  • Registered nursesRN hours only0.94hrsAbove only 48% of peers−0.12 vs MN avg
  • Licensed practical nursesLPN hours0.52hrs
  • Nurse aidesCNA hours2.24hrs
  • Weekend nursingAll staff on Saturdays and Sundays3.22hrs
  • Minnesota average
  • Research benchmark (4.10 total, 0.75 RN)

Turnover & capacity

  • Nursing staff turnoverShare who left within a year · lower is better51%Above only 26% of peersMN avg 42%
  • RN turnoverRegistered nurses only61%Not ranked by CMS
  • Administrators who leftIn the past year0Stable leadership
  • Occupancy140 certified beds · ~103 residents a day74%Above only 20% of peersMN avg 83%

Fines & penalties

Roughly the past three years

Enforcement summary

  • $244,730In fines
  • 3Fines
  • 0Payment denials
  • $19,953MN avg in fines
Lowest tier among peersMore in fines than nearly every rated home in Minnesota

Actions on record

  1. Mar 13, 2025Civil money penalty$22,315
  2. Jan 17, 2025Civil money penalty$26,130
  3. Sep 5, 2024Civil money penalty$196,285

Ownership

As filed with CMS

Structure

Ownership type
For profit - Limited Liability company
Chain
Independent
Certification
Medicare and Medicaid
Location type
Urban
Ownership change
None in the last 12 months

People and entities on file

Direct owners (5%+)
  • Ephraim Halpert
Operational or managerial control
  • Lisa Frey-Tykward
  • Steven Friedman
  • Gary Peterson
Corporate officers
  • Ephraim Halpert

Person Organization

Sources & notes

Public data, updated quarterly

Data sources

  • CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
  • CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
  • CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.

Notes

  • CMS Certification Number 245366 · 2501 RICE LAKE ROAD, DULUTH, MN, 55811.
  • Percentiles compare this facility with every rated nursing home in Minnesota and St. Louis County. Turnover and fines are inverted so a high percentile is always good.
  • This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.

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