Cycle 1
Health 2025-01-24 · Fire 2025-01-24
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
2 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Hendersonville, NC
Carolina Village Inc
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
600 Carolina Village Road SUITE Z, Hendersonville, NC
(828) 692-6275
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
58
Certified beds
Average residents
44
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1974-10-01
CMS approved date
Coverage
Medicare
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
1.52
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
1.19
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
3.97
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
6.67
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
2.70
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
5.91
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.92
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.13
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.73
CMS adjusted RN staffing hours
Adjusted total hours
7.62
CMS adjusted total nurse staffing hours
Case-mix index
1.20
Higher values indicate more complex resident acuity
RN turnover
31%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
25%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
92
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
86.64
Composite VBP score used to determine payment impact.
Payment multiplier
1.0269
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
9.07
Baseline 20.15% · Performance 17.23% · Measure score 9.07 · Achievement 9.07 · Improvement 8.86
Healthcare-associated infections
7.35
Baseline 5.33% · Performance 5.64% · Measure score 7.35 · Achievement 7.35 · Improvement 0
Total nurse turnover
8.24
Baseline 31.15% · Performance 30.00% · Measure score 8.24 · Achievement 8.24 · Improvement 1.32
Adjusted total nurse staffing
10
Baseline 5.81 hours · Performance 6.62 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.44% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 195 · Observed rate 5.64% · Lower 95% interval 6.62% |
| Discharge to community | 60.61% |
50.57%
10 pts better
|
Better than the National Rate · Eligible stays 179 · Observed rate 64.8% · Lower 95% interval 55.81% |
| Medicare spending per beneficiary | 0.74 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 96.2% |
95.27%
0.9 pts better
|
Numerator 177 · Denominator 184 |
| Falls with major injury | 0.54% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 184 |
| Discharge self-care score | 58.02% |
53.69%
4.3 pts better
|
Numerator 94 · Denominator 162 |
| Discharge mobility score | 67.9% |
50.94%
17 pts better
|
Numerator 110 · Denominator 162 |
| Pressure ulcers or injuries, new or worsened | 0.54% |
2.29%
1.8 pts better
|
Numerator 1 · Denominator 184 · Adjusted rate 0.73% |
| Healthcare-associated infections requiring hospitalization | 5.64% |
7.12%
1.5 pts better
|
No Different than the National Rate · Eligible stays 113 · Observed rate 1.77% · Lower 95% interval 3.4% |
| Staff COVID-19 vaccination coverage | 4.35% |
8.2%
3.8 pts worse
|
Numerator 9 · Denominator 207 |
| Staff flu vaccination coverage | 28.99% |
42%
13 pts worse
|
Numerator 89 · Denominator 307 |
| Discharge function score | 73.46% |
56.45%
17 pts better
|
Numerator 119 · Denominator 162 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 22 · Denominator 22 |
| Transfer of health information to patient | 99.22% |
96.28%
2.9 pts better
|
Numerator 127 · Denominator 128 |
| Resident COVID-19 vaccinations up to date | 39.5% |
25.2%
14.3 pts better
|
Numerator 47 · Denominator 119 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.5 |
1.8
1.3 pts better
|
1.9
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.5 · Observed 0.4 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.8
0.8 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.8 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.5%
8.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.1%
5.9 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 | 6.7% |
3.6%
3.1 pts worse
|
3.3%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 3.8% · Q3 6.7% · Q4 12.5% · 4Q avg 6.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.8%
4.8 pts better
|
11.4%
11.4 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 who lose too much weight | 3.6% |
7.2%
3.6 pts better
|
5.4%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.0% · Q3 5.0% · Q4 4.5% · 4Q avg 3.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.6% |
21.6%
4 pts worse
|
19.6%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.8% · Q2 20.0% · Q3 18.2% · Q4 39.1% · 4Q avg 25.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.3% |
15.0%
1.7 pts better
|
16.7%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 13.3% · 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 | 11.6% |
21.5%
9.9 pts better
|
16.3%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.1% |
16.8%
0.3 pts worse
|
14.9%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q3 22.7% · Q4 22.7% · 4Q avg 17.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
0.9%
0.3 pts worse
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.0% |
2.6%
0.6 pts better
|
1.7%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 7.7% · Q3 0.0% · Q4 0.0% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 37.2% |
21.2%
16 pts worse
|
19.8%
17.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 59.5% · Q2 34.6% · Q3 19.6% · Q4 39.3% · 4Q avg 37.2% |
| Percentage of long-stay residents with pressure ulcers | 3.5% |
6.0%
2.5 pts better
|
5.1%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.6% · Q3 3.8% · Q4 5.7% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.1% |
79.9%
19.2 pts better
|
81.7%
17.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.6% · Q2 99.4% · Q3 99.3% · Q4 99.3% · 4Q avg 99.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.2% |
13.2%
1 pts better
|
12.0%
0.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.2% · Observed 10.4% · Expected 9.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.2% |
78.1%
20.1 pts better
|
79.7%
18.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.4% |
22.9%
1.5 pts better
|
23.9%
2.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.4% · Observed 16.1% · Expected 17.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-13 · Fire 2023-10-13
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-08-04 · Fire 2022-08-04
4 health deficiencies
Top issue: Administration (1 deficiency)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-01-24
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-01-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-14
F · Potential for more than minimal harm
2023-10-13
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-01-14
F · Potential for more than minimal harm
2023-10-13
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 2024-01-14
D · Potential for more than minimal harm
2023-10-13
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-01-14
D · Potential for more than minimal harm
2023-10-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-01-14
E · Potential for more than minimal harm
2022-08-04
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2022-10-26
E · Potential for more than minimal harm
2022-08-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-26
D · Potential for more than minimal harm
2022-08-04
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-10-26
D · Potential for more than minimal harm
2022-08-04
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2022-10-26
D · Potential for more than minimal harm
2022-08-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-10-26
C · Minimal harm
2022-08-04
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 2022-10-26
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-01-24
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 2025-02-18
D · Potential for more than minimal harm
2025-01-24
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-02-18
B · Minimal harm
2023-10-13
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-10-30
E · Potential for more than minimal harm
2022-08-04
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 2022-10-14
E · Potential for more than minimal harm
2022-08-04
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2022-10-14
D · Potential for more than minimal harm
2022-08-04
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-09-07
B · Minimal harm
2022-08-04
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-09-07
Penalties and ownership
What sits behind the stars
Ownership
Nearby options
Other facilities in reach
#1
Life Care Center of Hendersonville
Hendersonville, NC
3-star overall rating with 2-star inspections with $40,986 in total fines with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
The Laurels of Hendersonville
Hendersonville, NC
3-star overall rating with 2-star inspections with $36,257 in total fines with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Valley Hill Health & Rehab Center
Hendersonville, NC
2-star overall rating with 2-star inspections with $58,949 in total fines with 6 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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