3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Marshall, NC
3-star overall rating with 3-star inspections with 3 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
415 Elderberry Lane, Marshall, NC
(828) 252-1790
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
80
Certified beds
Average residents
73
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1990-05-14
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.47
Registered nurse staffing
LPN hours / resident day
0.55
Licensed practical nurse staffing
Aide hours / resident day
2.01
Nurse aide staffing
Weekend hours
2.60
Weekend nurse staffing
RN turnover
33%
Annual RN turnover
Total nurse turnover
39%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.8
0.3 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 |
| 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 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.1% |
91.5%
1.6 pts better
|
93.4%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.6% |
94.1%
4.5 pts better
|
95.5%
3.1 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.1% |
3.6%
0.5 pts better
|
3.3%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 2.8% |
4.8%
2 pts better
|
11.4%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 7.9% |
7.2%
0.7 pts worse
|
5.4%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.1% |
21.6%
8.5 pts better
|
19.6%
6.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 31.3% |
15.0%
16.3 pts worse
|
16.7%
14.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.4% |
0.0%
0.4 pts worse
|
0.1%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 27.7% |
21.5%
6.2 pts worse
|
16.3%
11.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.7% |
16.8%
1.9 pts worse
|
14.9%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 6.7% |
2.6%
4.1 pts worse
|
1.7%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.3% |
21.2%
6.1 pts worse
|
19.8%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 13.9% |
6.0%
7.9 pts worse
|
5.1%
8.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.5% |
79.9%
11.6 pts better
|
81.7%
9.8 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.4% |
13.2%
3.8 pts better
|
12.0%
2.6 pts better
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.1% |
1.5%
2.6 pts worse
|
1.6%
2.5 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 49.3% |
78.1%
28.8 pts worse
|
79.7%
30.4 pts worse
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.9% |
22.9%
3 pts better
|
23.9%
4 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Top issue: Nutrition and Dietary (1 deficiency)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Nutrition and Dietary (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Top issue: Nutrition and Dietary (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2024-10-25
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 2024-12-19
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 2024-12-19
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-12-19
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-19
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-12-19
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-12-19
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-12-19
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-19
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-10-16
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-10-16
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-10-16
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 2023-10-16
Inspection history
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2026-01-15
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 2026-01-15
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2026-01-15
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-10-25
Health
Dispose of garbage and refuse properly.
Corrected 2024-10-25
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-10-25
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-10-25
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2024-10-25
Health
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
Corrected 2024-10-25
Health
Post nurse staffing information every day.
Corrected 2024-10-25
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-10-25
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-07-27
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-07-20
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-07-20
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2023-07-28
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-07-20
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-07-20
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-07-20
Penalties and ownership
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Officer · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Organization
Nearby options
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4-star overall rating with 4-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
Asheville, NC
2-star overall rating with 2-star inspections with $10,868 in total fines with 10 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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