Cycle 1
Health 2025-11-19 · Fire 2024-08-28
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Marshall, NC
Elderberry Health Care
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
Facility snapshot
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
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
0.47
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.55
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.01
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.03
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.02
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
2.60
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.23
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.48
CMS adjusted RN staffing hours
Adjusted total hours
3.12
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
39%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,595
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.83
Composite VBP score used to determine payment impact.
Payment multiplier
0.9822
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 17.25% · Performance 21.31% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
1.54
Baseline 5.04% · Performance 7.37% · Measure score 1.54 · Achievement 1.54 · Improvement 0
Total nurse turnover
4.49
Baseline 31.25% · Performance 45.31% · Measure score 4.49 · Achievement 4.49 · Improvement 0
Adjusted total nurse staffing
1.89
Baseline 2.44 hours · Performance 3.24 hours · Measure score 1.89 · Achievement 0.58 · Improvement 1.89
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.37% |
10.72%
1.4 pts better
|
No Different than the National Rate · Eligible stays 87 · Observed rate 5.75% · Lower 95% interval 6.67% |
| Discharge to community | 55.29% |
50.57%
4.7 pts better
|
No Different than the National Rate · Eligible stays 63 · Observed rate 55.56% · Lower 95% interval 46.1% |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 80 · Denominator 80 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 80 |
| Discharge self-care score | 41.79% |
53.69%
11.9 pts worse
|
Numerator 28 · Denominator 67 |
| Discharge mobility score | 41.79% |
50.94%
9.1 pts worse
|
Numerator 28 · Denominator 67 |
| Pressure ulcers or injuries, new or worsened | 10% |
2.29%
7.7 pts worse
|
Numerator 8 · Denominator 80 · Adjusted rate 12.65% |
| Healthcare-associated infections requiring hospitalization | 7.37% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 57 · Observed rate 7.02% · Lower 95% interval 3.79% |
| Staff COVID-19 vaccination coverage | 65.17% |
8.2%
57 pts better
|
Numerator 58 · Denominator 89 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 40.3% |
56.45%
16.2 pts worse
|
Numerator 27 · Denominator 67 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 36 · Denominator 36 |
| Resident COVID-19 vaccinations up to date | 29.79% |
25.2%
4.6 pts better
|
Numerator 14 · Denominator 47 |
Quality measures
Resident outcomes and process scores
| 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 · Adjusted 1.5 · Observed 1.6 · Expected 2.0 · 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 0.8 · Expected 1.7 · Used in QM five-star |
| 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 · Q1 92.5% · Q2 90.9% · Q3 93.8% · Q4 95.4% · 4Q avg 93.1% |
| 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 · 4Q avg 98.6% |
| 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 · Q1 1.5% · Q2 1.5% · Q3 4.7% · Q4 4.6% · 4Q avg 3.1% · Used in QM five-star |
| 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 · Q1 3.1% · Q2 1.6% · Q3 1.7% · Q4 4.8% · 4Q avg 2.8% |
| 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 · Q1 9.8% · Q2 6.5% · Q3 5.2% · Q4 10.0% · 4Q avg 7.9% |
| 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 · Q1 15.2% · Q2 12.7% · Q3 11.7% · Q4 12.9% · 4Q avg 13.1% |
| 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 · Q1 34.8% · Q2 37.5% · Q3 30.6% · Q4 23.1% · 4Q avg 31.3% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 1.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% |
| 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 · Q1 21.5% · Q2 31.6% · Q3 40.7% · Q4 14.9% · 4Q avg 27.7% · Used in QM five-star |
| 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 · Q1 21.2% · Q2 15.9% · Q3 24.6% · Q4 13.3% · 4Q avg 18.7% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| 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 · Q1 8.1% · Q2 7.7% · Q3 8.1% · Q4 3.2% · 4Q avg 6.7% · Used in QM five-star |
| 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 · Q1 29.6% · Q2 30.1% · Q3 21.3% · Q4 27.7% · 4Q avg 27.3% |
| 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 · Q1 16.3% · Q2 11.8% · Q3 9.5% · Q4 18.1% · 4Q avg 13.9% · Used in QM five-star |
| 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 · Q1 96.1% · Q2 88.3% · Q3 90.5% · Q4 91.9% · 4Q avg 91.5% |
| 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 · Adjusted 9.4% · Observed 9.9% · Expected 11.8% · Used in QM five-star |
| 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 · Q1 3.3% · Q2 0.0% · Q3 3.4% · Q4 7.9% · 4Q avg 4.1% · Used in QM five-star |
| 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 · 4Q avg 49.3% |
| 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 · Adjusted 19.9% · Observed 19.7% · Expected 23.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-28 · Fire 2023-06-22
8 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-06-22 · Fire 2021-10-28
7 health 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 citations
F · Potential for more than minimal harm
2024-08-28
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2024-10-25
D · Potential for more than minimal harm
2024-08-28
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 2024-12-19
D · Potential for more than minimal harm
2024-08-28
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 2024-12-19
D · Potential for more than minimal harm
2024-08-28
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-12-19
D · Potential for more than minimal harm
2024-08-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-19
D · Potential for more than minimal harm
2024-08-28
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-12-19
D · Potential for more than minimal harm
2024-08-28
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-12-19
D · Potential for more than minimal harm
2024-08-28
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-12-19
D · Potential for more than minimal harm
2024-08-28
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-19
E · Potential for more than minimal harm
2023-06-22
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-10-16
E · Potential for more than minimal harm
2023-06-22
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-10-16
E · Potential for more than minimal harm
2023-06-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-10-16
D · Potential for more than minimal harm
2023-06-22
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 2023-10-16
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-11-19
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 2026-01-15
D · Potential for more than minimal harm
2025-11-19
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 2026-01-15
D · Potential for more than minimal harm
2025-11-19
F690 · Quality of Life and Care Deficiencies
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
F · Potential for more than minimal harm
2024-08-28
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 2024-10-25
E · Potential for more than minimal harm
2024-08-28
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-10-25
D · Potential for more than minimal harm
2024-08-28
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
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
D · Potential for more than minimal harm
2024-08-28
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-10-25
D · Potential for more than minimal harm
2024-08-28
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2024-10-25
C · Minimal harm
2024-08-28
F575 · Resident Rights Deficiencies
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
C · Minimal harm
2024-08-28
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-10-25
B · Minimal harm
2024-08-28
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 2024-10-25
F · Potential for more than minimal harm
2023-06-22
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 2023-07-27
E · Potential for more than minimal harm
2023-06-22
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-07-20
E · Potential for more than minimal harm
2023-06-22
F803 · Nutrition and Dietary Deficiencies
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
E · Potential for more than minimal harm
2023-06-22
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2023-07-28
D · Potential for more than minimal harm
2023-06-22
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-07-20
D · Potential for more than minimal harm
2023-06-22
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-07-20
B · Minimal harm
2023-06-22
F584 · Resident Rights Deficiencies
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
What sits behind the stars
Ownership
Martin, James
5% Or Greater Indirect Ownership Interest · Individual
Charlotte Advance, Inc
5% Or Greater Direct Ownership Interest · Organization
Cutshall, Karen
Operational/Managerial Control · Individual
Elderberry Of Marshall, LLC
5% Or Greater Direct Ownership Interest · Organization
Eller, Edward
Operational/Managerial Control · Individual
Eller, Edward
Corporate Officer · Individual
Martin, Andrew
Operational/Managerial Control · Individual
Martin, James
Operational/Managerial Control · Individual
Martin, James
Corporate Officer · Individual
Tullock Management Company
Operational/Managerial Control · Organization
Wilkinson Care Center, Inc.
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Madison Health and Rehabilitation
Mars Hill, NC
3-star overall rating with 2-star inspections with abuse icon flag with $14,015 in total fines with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
The Greens at Weaverville
Weaverville, NC
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Emerald Ridge Health and Rehabilitation
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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