Hilltop Healthcare Rehabilitation and Skilled Nurs
2501 Rice Lake Road, Duluth, MN 55811 · St. Louis County · 140 certified beds · avg 105 residents/day · certified since Aug 1, 1986
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Jan 17, 2025 · F-0678 · triggered by a complaint
The facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes.
Why it matters: In a cardiac or breathing emergency, failure to start CPR promptly can be the difference between life and death.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jan 15, 2025 (Past Non-Compliance)
▲ Immediate jeopardy, one-off · Sep 5, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Sep 27, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Mar 13, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Mar 6, 2025 (Past Non-Compliance)
All citations in the current public record (35)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Mar 12, 2026 | F · Potential for harm, facility-wide | The facility did not have enough support staff to safely and effectively run its food and nutrition service. |
| Mar 12, 2026 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Mar 12, 2026 | D · Potential for harm, one-off | The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. |
| Mar 12, 2026 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. |
| Mar 12, 2026 | D · Potential for harm, one-off | The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). |
| Mar 12, 2026 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Mar 12, 2026 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Mar 12, 2026 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Mar 12, 2026 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| Mar 12, 2026 | C · Minimal risk, facility-wide | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. |
| May 2, 2025 | F · Potential for harm, facility-wide | The facility did not serve meals and snacks at times that fit residents' needs, preferences, and requests, or did not offer nourishing alternatives for residents who want to eat outside scheduled meal times. |
| May 2, 2025 | D · Potential for harm, one-off | The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. |
| May 2, 2025 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| May 2, 2025 | D · Potential for harm, one-off | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. |
| May 2, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| May 2, 2025 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| May 2, 2025 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| May 2, 2025 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. |
| May 2, 2025 | D · Potential for harm, one-off | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. |
| May 2, 2025 | D · Potential for harm, one-off | The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason. |
| May 2, 2025 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Mar 13, 2025 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jan 17, 2025 | ▲ J · Immediate jeopardy, one-off | The facility did not provide basic life support, such as CPR, before emergency medical help arrived — care that's required when it matches the doctor's orders and the resident's own written wishes. · from a complaint |
| Sep 5, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Sep 5, 2024 | D · Potential for harm, one-off | The facility did not make sure its nurse aides had the skills needed to care for residents, including training in dementia care and abuse prevention. · from a complaint |
| Sep 5, 2024 | C · Minimal risk, facility-wide | The facility did not give all staff the required training on its quality improvement program — the internal system for finding problems and making care better. · from a complaint |
| Feb 16, 2024 | E · Potential for harm, repeated | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Feb 16, 2024 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Feb 16, 2024 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Feb 16, 2024 | E · Potential for harm, repeated | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
| Feb 16, 2024 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Feb 16, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Feb 16, 2024 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Feb 16, 2024 | C · Minimal risk, facility-wide | The facility did not make its inspection results easy for residents to see, or made it hard for residents to contact advocacy agencies like the ombudsman. |
| Nov 22, 2023 | D · Potential for harm, one-off | The facility transferred or discharged a resident without a valid reason, or failed to provide the required documentation and information when moving a resident out. · from a complaint |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (11 → 10).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 1 | 0 | D |
| 2024 | 11 | 1 | J ▲ |
| 2025 | 13 | 2 | J ▲ |
| 2026 | 10 | 0 | F |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
3 fines totaling $170,619.
| Date | Type | Amount / length |
|---|---|---|
| Mar 13, 2025 | Fine | $14,717 |
| Jan 17, 2025 | Fine | $26,130 |
| Sep 5, 2024 | Fine | $129,772 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Minnesota avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.12 | 4.83 | 3.95 | bottom 20% in Minnesota; top 35% in the U.S. |
| Registered Nurse hours | 1.19 | 1.22 | 0.69 | top 43% in Minnesota; top 10% in the U.S. |
| Weekend total nurse staffing | 3.85 | 4.27 | 3.50 | bottom 32% in Minnesota; top 28% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.70 | 0.69 | 0.48 | top 37% in Minnesota; top 16% in the U.S. |
| Total nursing staff turnover (%) | 50.0 | 42.2 | 45.8 | bottom 28% in Minnesota; bottom 38% in the U.S. |
| RN turnover (%) | 42.9 | 38.6 | 42.9 | bottom 39% in Minnesota; bottom 49% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.31, RN 0.96, weekend 3.09. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 2/5 · long-stay residents: 2/5 · short-stay residents: 1/5
Who owns this facility
For profit - Partnership
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Halpert, Ephraim | Individual | 5% or Greater Direct Ownership Interest | 100% | 06/08/2022 |
| Abbas Jam Trust | Organization | ADP of the SNF | NOT APPLICABLE | 06/08/2022 |
| Anderson, Lindsey | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/09/2023 |
| Anderson, Lindsey | Individual | ADP of the SNF | NOT APPLICABLE | 01/09/2023 |
| Berlin, Alexander | Individual | Operational/Managerial Control | NOT APPLICABLE | 01/27/2025 |
| Berlin, Alexander | Individual | ADP of the SNF | NOT APPLICABLE | 01/27/2025 |
| Cliftonlarsonallen LLP | Organization | ADP of the SNF | NOT APPLICABLE | 06/08/2022 |
| Deutsch, David | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 12/23/2025 |
| Dunn, Daniel | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/26/2024 |
| Dunn, Daniel | Individual | ADP of the SNF | NOT APPLICABLE | 08/26/2024 |
| Elliot DK LLC | Organization | ADP of the SNF | NOT APPLICABLE | 06/08/2022 |
| Finlay, Alison | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/07/2024 |
| Finlay, Alison | Individual | ADP of the SNF | NOT APPLICABLE | 10/07/2024 |
| Frey-Tykward, Lisa | Individual | Operational/Managerial Control | NOT APPLICABLE | 06/17/2024 |
| Frey-Tykward, Lisa | Individual | ADP of the SNF | NOT APPLICABLE | 06/17/2024 |
| Friedman, David | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 12/23/2025 |
| Friedman, Steven | Individual | Operational/Managerial Control | NOT APPLICABLE | 06/08/2022 |
| Friedman, Steven | Individual | ADP of the SNF | NOT APPLICABLE | 06/08/2022 |
| Halpert, Ephraim | Individual | ADP of the SNF | NOT APPLICABLE | 06/08/2022 |
| Hillel Tauber Pension Fund | Organization | ADP of the SNF | NOT APPLICABLE | 06/08/2022 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Are staff on every shift trained and certified in CPR, and how do they know each resident's resuscitation wishes?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How is your kitchen staffed, and have meals ever been delayed because of staffing?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
- "If someone reports suspected abuse or neglect here, what happens in the first 24 hours?"
- "What written notices do we get before any transfer or discharge, and what is your bed-hold policy?"
- "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Benedictine Health Center | 1.3 mi | Duluth, MN | ★☆☆☆☆ | 1/5 | abuse |
| Aftenro Home | 1.7 mi | Duluth, MN | ★☆☆☆☆ | 1/5 | |
| Viewcrest Health Center | 2.9 mi | Duluth, MN | ★★★☆☆ | 3/5 | |
| Bayshore Residence and Rehabilitation Center | 4.0 mi | Duluth, MN | ★★☆☆☆ | 2/5 | |
| Ecumen Lakeshore | 4.0 mi | Duluth, MN | ★★★★★ | 5/5 | |
| Franciscan Health Center | 6.0 mi | Duluth, MN | ★☆☆☆☆ | 2/5 | |
| Dove Healthcare - Superior | 7.0 mi | Superior, WI | ★★☆☆☆ | 2/5 | |
| The North Shore Estates LLC | 7.4 mi | Duluth, MN | ★★☆☆☆ | 2/5 | |
| Villa Marina Health and Rehabilitation Center | 8.1 mi | Superior, WI | ★★★★☆ | 3/5 | |
| Twin Ports Health Services | 8.6 mi | Superior, WI | ★★★★★ | 4/5 | |
| Interfaith Care Center | 17.4 mi | Carlton, MN | ★★★★★ | 4/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 245366.