Cycle 1
Health 2025-02-13 · Fire 2025-02-13
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
2 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Forest City, NC
Fair Haven of Forest City, LLC
4-star overall rating with 5-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
830 Bethany Church Road, Forest City, NC
(828) 245-2852
Overall
4 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
85
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1990-04-06
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
0.36
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.98
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.28
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.62
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.34
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.40
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.19
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
0.37
CMS adjusted RN staffing hours
Adjusted total hours
3.73
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
70%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
30%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,735
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.92
Composite VBP score used to determine payment impact.
Payment multiplier
0.9852
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.17% · Performance 23.81% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
2.31
Baseline 5.79% · Performance 7.14% · Measure score 2.31 · Achievement 2.31 · Improvement 0
Total nurse turnover
6.07
Baseline 30.86% · Performance 38.89% · Measure score 6.07 · Achievement 6.07 · Improvement 0
Adjusted total nurse staffing
3.19
Baseline 4.35 hours · Performance 3.99 hours · Measure score 3.19 · Achievement 3.19 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 14.16% |
10.72%
3.4 pts worse
|
No Different than the National Rate · Eligible stays 162 · Observed rate 16.05% · Lower 95% interval 10.42% |
| Discharge to community | 51.7% |
50.57%
1.1 pts better
|
No Different than the National Rate · Eligible stays 149 · Observed rate 51.01% · Lower 95% interval 42.43% |
| Medicare spending per beneficiary | 0.87 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.28% |
95.27%
3 pts better
|
Numerator 114 · Denominator 116 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 116 |
| Discharge self-care score | 64.04% |
53.69%
10.4 pts better
|
Numerator 57 · Denominator 89 |
| Discharge mobility score | 46.07% |
50.94%
4.9 pts worse
|
Numerator 41 · Denominator 89 |
| Pressure ulcers or injuries, new or worsened | 8.62% |
2.29%
6.3 pts worse
|
Numerator 10 · Denominator 116 · Adjusted rate 7.31% |
| Healthcare-associated infections requiring hospitalization | 7.14% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 83 · Observed rate 6.02% · Lower 95% interval 3.91% |
| Staff COVID-19 vaccination coverage | 0.72% |
8.2%
7.5 pts worse
|
Numerator 1 · Denominator 138 |
| Staff flu vaccination coverage | 4.14% |
42%
37.9 pts worse
|
Numerator 6 · Denominator 145 |
| Discharge function score | 56.18% |
56.45%
0.3 pts worse
|
Numerator 50 · Denominator 89 |
| Transfer of health information to provider | 98.18% |
95.95%
2.2 pts better
|
Numerator 54 · Denominator 55 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 25 · Denominator 25 |
| Resident COVID-19 vaccinations up to date | 11.59% |
25.2%
13.6 pts worse
|
Numerator 8 · Denominator 69 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
1.8
0.7 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.2 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 4.2 |
1.8
2.4 pts worse
|
1.8
2.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 4.2 · Observed 3.5 · 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 | 98.8% |
94.1%
4.7 pts better
|
95.5%
3.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.8% |
3.6%
2.2 pts worse
|
3.3%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 5.5% · Q3 2.7% · Q4 8.1% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.0% |
4.8%
1.8 pts better
|
11.4%
8.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.5% · Q3 5.9% · Q4 2.9% · 4Q avg 3.0% |
| Percentage of long-stay residents who lose too much weight | 8.5% |
7.2%
1.3 pts worse
|
5.4%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.3% · Q2 9.4% · Q3 4.9% · Q4 7.8% · 4Q avg 8.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 42.7% |
21.6%
21.1 pts worse
|
19.6%
23.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.3% · Q2 40.0% · Q3 44.4% · Q4 46.2% · 4Q avg 42.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.3% |
15.0%
5.7 pts better
|
16.7%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 9.3% · Q3 5.7% · Q4 10.5% · 4Q avg 9.3% · 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 | 20.6% |
21.5%
0.9 pts better
|
16.3%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.1% · Q2 19.8% · Q3 25.4% · Q4 20.8% · 4Q avg 20.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.4% |
16.8%
1.4 pts better
|
14.9%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 10.0% · Q3 25.0% · Q4 9.7% · 4Q avg 15.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.8% |
0.9%
0.9 pts worse
|
1.0%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 1.2% · Q3 0.9% · Q4 0.9% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 7.0% |
2.6%
4.4 pts worse
|
1.7%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.4% · Q2 4.2% · Q3 6.8% · Q4 6.8% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 23.2% |
21.2%
2 pts worse
|
19.8%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.9% · Q2 31.1% · Q3 21.6% · Q4 16.7% · 4Q avg 23.2% |
| Percentage of long-stay residents with pressure ulcers | 6.6% |
6.0%
0.6 pts worse
|
5.1%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 9.6% · Q3 7.6% · Q4 4.4% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.9% |
79.9%
15 pts better
|
81.7%
13.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.1% · Q2 93.7% · Q3 96.7% · Q4 100.0% · 4Q avg 94.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 27.1% |
13.2%
13.9 pts worse
|
12.0%
15.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.1% · Observed 23.4% · Expected 9.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.5%
1.2 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.5% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.6% |
78.1%
8.5 pts better
|
79.7%
6.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 86.6% |
| 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 25.2% · Expected 22.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-16 · Fire 2023-11-16
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-06-09 · Fire 2022-06-09
4 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-02-13
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-03-17
D · Potential for more than minimal harm
2025-02-13
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-03-17
D · Potential for more than minimal harm
2023-11-16
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-01-10
D · Potential for more than minimal harm
2023-11-16
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-01-10
D · Potential for more than minimal harm
2023-11-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-01-10
D · Potential for more than minimal harm
2022-06-09
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2022-09-01
D · Potential for more than minimal harm
2022-06-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-09-01
D · Potential for more than minimal harm
2022-06-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-09-01
D · Potential for more than minimal harm
2022-06-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-09-01
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-02-13
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 2025-03-01
E · Potential for more than minimal harm
2023-11-16
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 2023-12-11
D · Potential for more than minimal harm
2023-11-16
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 2023-12-11
E · Potential for more than minimal harm
2022-06-09
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2022-06-28
E · Potential for more than minimal harm
2022-06-09
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2022-06-28
D · Potential for more than minimal harm
2022-06-09
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 2022-06-28
D · Potential for more than minimal harm
2022-06-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-06-28
Penalties and ownership
What sits behind the stars
Ownership
Cilone, John
5% Or Greater Direct Ownership Interest · Individual
Hensley, Suzanne
5% Or Greater Direct Ownership Interest · Individual
Mckeithan, Charles
5% Or Greater Direct Ownership Interest · Individual
Mckeithan, Daniel
5% Or Greater Direct Ownership Interest · Individual
Mckeithan, Emmett
5% Or Greater Direct Ownership Interest · Individual
Cilone, John
Operational/Managerial Control · Individual
Hensley, Suzanne
Operational/Managerial Control · Individual
Mckeithan, Charles
Operational/Managerial Control · Individual
Mckeithan, Daniel
Operational/Managerial Control · Individual
Mckeithan, Emmett
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Fair Haven Home Inc
Bostic, NC
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Willow Ridge Of NC
Rutherfordton, NC
1-star overall rating with 1-star inspections with abuse icon flag with $146,939 in total fines with 12 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Oak Grove Healthcare
Rutherfordton, NC
4-star overall rating with 5-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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