McLeansville, NC

Ashton Health and Rehabilitation

4-star overall rating with 4-star inspections with $8,788 in total fines with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle

5533 Burlington Road, McLeansville, NC

(336) 698-0045

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

134

Certified beds

Average residents

120

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Sanstone Health & Rehabilitation

Operator or chain grouping

Approved since

2009-11-19

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

17 facilities

Chain averages 4 overall / 4 health / 3 staffing / 4 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

0.19

Registered nurse staffing · state 0.59 · national 0.68

LPN hours / resident day

0.97

Licensed practical nurse staffing · state 0.87 · national 0.87

Aide hours / resident day

2.59

Nurse aide staffing · state 2.33 · national 2.35

Total nurse hours

3.75

All reported nurse hours · state 3.78 · national 3.89

Licensed hours

1.16

RN + LPN hours · state 1.45 · national 1.54

Weekend hours

3.35

Weekend nurse staffing · state 3.34 · national 3.43

Weekend RN hours

0.15

Weekend registered nurse coverage · state 0.38 · national 0.47

Physical therapist

0.12

Reported PT staffing · state 0.09 · national 0.07

Adjusted RN hours

0.19

CMS adjusted RN staffing hours

Adjusted total hours

3.71

CMS adjusted total nurse staffing hours

Case-mix index

1.38

Higher values indicate more complex resident acuity

RN turnover

53%

Annual RN turnover · state 48% · national 45%

Total nurse turnover

48%

Annual nurse turnover · state 50% · national 46%

SNF VBP

Value-based purchasing

Program rank

4,642

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

39.13

Composite VBP score used to determine payment impact.

Payment multiplier

0.9921

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

4.33

Baseline 18.58% · Performance 19.43% · Measure score 4.33 · Achievement 4.33 · Improvement 0

Healthcare-associated infections

5.40

Baseline 5.63% · Performance 6.22% · Measure score 5.40 · Achievement 5.40 · Improvement 0

Total nurse turnover

3.46

Baseline 58.33% · Performance 49.52% · Measure score 3.46 · Achievement 3.46 · Improvement 2.13

Adjusted total nurse staffing

2.46

Baseline 3.68 hours · Performance 3.78 hours · Measure score 2.46 · Achievement 2.46 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	9.22%	10.72% 1.5 pts better	No Different than the National Rate · Eligible stays 109 · Observed rate 6.42% · Lower 95% interval 5.97%
Discharge to community	61.49%	50.57% 10.9 pts better	Better than the National Rate · Eligible stays 110 · Observed rate 55.45% · Lower 95% interval 51.49%
Medicare spending per beneficiary	1.22	1.02 0.2 pts worse
Drug regimen review with follow-up	98.7%	95.27% 3.4 pts better	Numerator 76 · Denominator 77
Falls with major injury	1.3%	0.77% 0.5 pts worse	Numerator 1 · Denominator 77
Discharge self-care score	51.79%	53.69% 1.9 pts worse	Numerator 29 · Denominator 56
Discharge mobility score	46.43%	50.94% 4.5 pts worse	Numerator 26 · Denominator 56
Pressure ulcers or injuries, new or worsened	2.6%	2.29% 0.3 pts worse	Numerator 2 · Denominator 77 · Adjusted rate 2.82%
Healthcare-associated infections requiring hospitalization	6.22%	7.12% 0.9 pts better	No Different than the National Rate · Eligible stays 73 · Observed rate 4.11% · Lower 95% interval 3.91%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 153
Staff flu vaccination coverage	9.56%	42% 32.4 pts worse	Numerator 24 · Denominator 251
Discharge function score	62.5%	56.45% 6 pts better	Numerator 35 · Denominator 56
Transfer of health information to provider	87.8%	95.95% 8.2 pts worse	Numerator 36 · Denominator 41
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 20 · Denominator 20
Resident COVID-19 vaccinations up to date	15.69%	25.2% 9.5 pts worse	Numerator 8 · Denominator 51

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.2	1.8 0.6 pts better	1.9 0.7 pts better	Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.0 · Expected 1.6 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.2	1.8 0.6 pts better	1.8 0.6 pts better	Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.0 · Expected 1.4 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	93.9%	91.5% 2.4 pts better	93.4% 0.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 97.8% · Q2 96.5% · Q3 87.6% · Q4 93.4% · 4Q avg 93.9%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	95.7%	94.1% 1.6 pts better	95.5% 0.2 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 95.7%
Percentage of long-stay residents experiencing one or more falls with major injury	3.6%	3.6% About the same	3.3% 0.3 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 3.5% · Q3 3.4% · Q4 6.6% · 4Q avg 3.6% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	3.1%	4.8% 1.7 pts better	11.4% 8.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 6.0% · Q3 2.2% · Q4 2.2% · 4Q avg 3.1%
Percentage of long-stay residents who lose too much weight	5.1%	7.2% 2.1 pts better	5.4% 0.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 5.5% · Q3 2.8% · Q4 9.6% · 4Q avg 5.1%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	18.0%	21.6% 3.6 pts better	19.6% 1.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 24.4% · Q2 16.2% · Q3 15.1% · Q4 16.0% · 4Q avg 18.0%
Percentage of long-stay residents who received an antipsychotic medication	11.2%	15.0% 3.8 pts better	16.7% 5.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 13.8% · Q2 8.6% · Q3 10.9% · Q4 11.1% · 4Q avg 11.2% · 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	22.0%	21.5% 0.5 pts worse	16.3% 5.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q4 8.6% · 4Q avg 22.0% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	11.6%	16.8% 5.2 pts better	14.9% 3.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 13.1% · Q2 21.9% · Q3 6.1% · Q4 5.9% · 4Q avg 11.6% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.2%	0.9% 0.7 pts better	1.0% 0.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.6%	2.6% 2 pts better	1.7% 1.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 1.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	18.8%	21.2% 2.4 pts better	19.8% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 33.5% · Q3 20.0% · Q4 13.4% · 4Q avg 18.8%
Percentage of long-stay residents with pressure ulcers	3.1%	6.0% 2.9 pts better	5.1% 2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 1.9% · Q3 3.5% · Q4 2.9% · 4Q avg 3.1% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	88.5%	79.9% 8.6 pts better	81.7% 6.8 pts better	Short Stay · 2024Q4-2025Q3 · Q1 90.1% · Q2 92.1% · Q3 88.0% · Q4 84.7% · 4Q avg 88.5%
Percentage of short-stay residents who had an outpatient emergency department visit	11.5%	13.2% 1.7 pts better	12.0% 0.5 pts better	Short Stay · 20240701-20250630 · Adjusted 11.5% · Observed 10.0% · Expected 9.7% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.7%	1.5% 0.8 pts better	1.6% 0.9 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.2% · Q4 1.1% · 4Q avg 0.7% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	93.2%	78.1% 15.1 pts better	79.7% 13.5 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 93.2%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	27.2%	22.9% 4.3 pts worse	23.9% 3.3 pts worse	Short Stay · 20240701-20250630 · Adjusted 27.2% · Observed 24.5% · Expected 21.5% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-07-03 · Fire 2024-05-01

1 health deficiencies

Top issue: Quality of Life and Care (1 deficiency)

1 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 2 Health 2024-05-01 · Fire 2023-04-28

2 health deficiencies

Top issue: Administration (1 deficiency)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Cycle 3 Health 2023-04-28 · Fire 2021-11-19

2 health deficiencies

Top issue: Resident Rights (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 2024-05-01

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 2024-06-20

Inspection history

Recent health citations

G · Actual harm 2025-04-30

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 2025-04-11

D · Potential for more than minimal harm 2024-05-01

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 2024-04-12

D · Potential for more than minimal harm 2024-05-01

F867 · Administration Deficiencies

Health

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected 2024-05-18

D · Potential for more than minimal harm 2023-04-28

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 2023-05-16

D · Potential for more than minimal harm 2023-04-28

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 2023-05-16

Penalties and ownership