Cycle 1
Health 2025-04-03 · Fire 2025-04-03
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Asheville, NC
Deerfield Episcopal Retirement
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
1617 Hendersonville Road, Asheville, NC
(828) 274-1531
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
62
Certified beds
Average residents
61
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2013-01-23
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
1.54
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.70
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
3.01
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
5.26
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
2.25
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
4.59
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
1.11
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.71
CMS adjusted RN staffing hours
Adjusted total hours
5.82
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
16%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
31%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,304
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
33.34
Composite VBP score used to determine payment impact.
Payment multiplier
0.9876
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Performance 21.37% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
3.33
Baseline 5.98% · Performance 6.84% · Measure score 3.33 · Achievement 3.33 · Improvement 0
Total nurse turnover
0
Performance 83.70% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
10
Baseline 7.67 hours · Performance 6.56 hours · Measure score 10 · Achievement 10 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.11% |
10.72%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 46 · Observed rate 10.87% · Lower 95% interval 7.49% |
| Discharge to community | 49.87% |
50.57%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 35 · Observed rate 48.57% · Lower 95% interval 39.67% |
| Medicare spending per beneficiary | 0.84 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 77.78% |
95.27%
17.5 pts worse
|
Numerator 28 · Denominator 36 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 36 |
| Discharge self-care score | 42.86% |
53.69%
10.8 pts worse
|
Numerator 12 · Denominator 28 |
| Discharge mobility score | 50% |
50.94%
0.9 pts worse
|
Numerator 14 · Denominator 28 |
| Pressure ulcers or injuries, new or worsened | 5.56% |
2.29%
3.3 pts worse
|
Numerator 2 · Denominator 36 · Adjusted rate 5.14% |
| Healthcare-associated infections requiring hospitalization | 6.84% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 27 · Observed rate 3.7% · Lower 95% interval 3.33% |
| Staff COVID-19 vaccination coverage | 0.74% |
8.2%
7.5 pts worse
|
Numerator 2 · Denominator 271 |
| Staff flu vaccination coverage | 38.12% |
42%
3.9 pts worse
|
Numerator 77 · Denominator 202 |
| Discharge function score | 64.29% |
56.45%
7.8 pts better
|
Numerator 18 · Denominator 28 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.8
0.1 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.2 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.8
1 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 0.6 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.0% |
91.5%
4.5 pts better
|
93.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.1% · Q2 96.5% · Q3 96.3% · Q4 93.3% · 4Q avg 96.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.3% |
94.1%
4.2 pts better
|
95.5%
2.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.3% |
| 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 5.8% · Q2 8.8% · Q3 5.6% · Q4 6.7% · 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 | 4.6% |
7.2%
2.6 pts better
|
5.4%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 7.7% · Q3 2.9% · Q4 2.3% · 4Q avg 4.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.8% |
21.6%
10.8 pts better
|
19.6%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.8% · Q2 10.3% · Q3 10.8% · Q4 11.1% · 4Q avg 10.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.1% |
15.0%
7.1 pts worse
|
16.7%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 17.6% · Q3 22.9% · Q4 24.3% · 4Q avg 22.1% · 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 | 19.7% |
21.5%
1.8 pts better
|
16.3%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.7% · Q2 34.1% · Q3 19.4% · 4Q avg 19.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.3% |
16.8%
3.5 pts worse
|
14.9%
5.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.7% · Q2 26.3% · Q3 13.9% · Q4 15.9% · 4Q avg 20.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.6% |
0.9%
0.7 pts worse
|
1.0%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 1.4% · Q4 3.8% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 6.0% |
2.6%
3.4 pts worse
|
1.7%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 7.1% · Q3 7.8% · Q4 5.3% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 36.6% |
21.2%
15.4 pts worse
|
19.8%
16.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 44.8% · Q2 41.0% · Q3 40.3% · Q4 21.4% · 4Q avg 36.6% |
| Percentage of long-stay residents with pressure ulcers | 11.2% |
6.0%
5.2 pts worse
|
5.1%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.3% · Q2 8.4% · Q3 8.0% · Q4 11.3% · 4Q avg 11.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 84.7% |
79.9%
4.8 pts better
|
81.7%
3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 79.4% · Q2 82.8% · Q3 83.9% · 4Q avg 84.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 0.0% |
13.2%
13.2 pts better
|
12.0%
12 pts better
|
Short Stay · 20240701-20250630 · Adjusted 0.0% · Observed 0.0% · Expected 9.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.0% |
1.5%
2.5 pts worse
|
1.6%
2.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 4.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 83.3% |
78.1%
5.2 pts better
|
79.7%
3.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 83.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.9% |
22.9%
1 pts better
|
23.9%
2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.9% · Observed 16.7% · Expected 18.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-08 · Fire 2024-02-08
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-07-08 · Fire 2022-07-08
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-03
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 2025-05-28
F · Potential for more than minimal harm
2025-04-03
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-05-28
D · Potential for more than minimal harm
2025-04-03
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-05-28
D · Potential for more than minimal harm
2024-02-08
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-04-20
D · Potential for more than minimal harm
2024-02-08
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-04-20
D · Potential for more than minimal harm
2024-02-08
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-04-20
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-04-03
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 2025-05-05
E · Potential for more than minimal harm
2024-02-08
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 2024-03-06
Penalties and ownership
What sits behind the stars
Ownership
Bush, Elizabeth
Corporate Officer · Individual
Bush, Elizabeth
W-2 Managing Employee · Individual
Chandler, Robert
Corporate Officer · Individual
King, Brian
Operational/Managerial Control · Individual
Sharpe, Matthew
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Givens Health Center
Asheville, NC
4-star overall rating with 3-star inspections with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Biltmore Haven Nursing and Rehabilitation
Arden, NC
1-star overall rating with 1-star inspections with Special Focus status with $172,134 in total fines with 17 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
The Laurels Of Greentree Ridge
Asheville, NC
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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