Cycle 1
Health 2025-06-02 · Fire 2024-02-02
24 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fletcher, NC
Fletcher Rehabilitation and Healthcare Center
1-star overall rating with 1-star inspections with abuse icon flag with $67,600 in total fines with 24 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
86 Old Airport Road, Fletcher, NC
(828) 654-9060
Overall
1 / 5
CMS overall stars
Health inspections
1 / 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
90
Certified beds
Average residents
73
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Yad Healthcare
Operator or chain grouping
Approved since
2003-01-29
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
13 facilities
Chain averages 2 overall / 2 health / 2 staffing / 3 quality stars
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
0.65
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.66
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.06
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.37
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.31
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
2.89
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.43
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
0.69
CMS adjusted RN staffing hours
Adjusted total hours
3.54
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
78%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
75%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,845
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.49
Composite VBP score used to determine payment impact.
Payment multiplier
0.9838
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.13
Baseline 21.25% · Performance 19.52% · Measure score 4.13 · Achievement 4.13 · Improvement 3.60
Healthcare-associated infections
3.52
Baseline 9.00% · Performance 7.39% · Measure score 3.52 · Achievement 1.48 · Improvement 3.52
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
0
Baseline 3.32 hours · Performance 3.14 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.48% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 80 · Observed rate 13.75% · Lower 95% interval 7.81% |
| Discharge to community | 54.44% |
50.57%
3.9 pts better
|
No Different than the National Rate · Eligible stays 70 · Observed rate 48.57% · Lower 95% interval 41.83% |
| Medicare spending per beneficiary | 1.16 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 96.97% |
95.27%
1.7 pts better
|
Numerator 64 · Denominator 66 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 66 |
| Discharge self-care score | 17.78% |
53.69%
35.9 pts worse
|
Numerator 8 · Denominator 45 |
| Discharge mobility score | 37.78% |
50.94%
13.2 pts worse
|
Numerator 17 · Denominator 45 |
| Pressure ulcers or injuries, new or worsened | 9.09% |
2.29%
6.8 pts worse
|
Numerator 6 · Denominator 66 · Adjusted rate 10.39% |
| Healthcare-associated infections requiring hospitalization | 7.39% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 60 · Observed rate 8.33% · Lower 95% interval 4.22% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 127 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 109 |
| Discharge function score | 42.22% |
56.45%
14.2 pts worse
|
Numerator 19 · Denominator 45 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 23 · Denominator 23 |
| Transfer of health information to patient | 91.67% |
96.28%
4.6 pts worse
|
Numerator 22 · Denominator 24 |
| Resident COVID-19 vaccinations up to date | 15.38% |
25.2%
9.8 pts worse
|
Numerator 6 · Denominator 39 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.8
0.2 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.1 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
1.8
0.5 pts worse
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.4 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 87.9% |
91.5%
3.6 pts worse
|
93.4%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 94.2% · Q2 88.1% · Q3 87.9% · Q4 80.6% · 4Q avg 87.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.9% |
94.1%
1.8 pts better
|
95.5%
0.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.9% |
3.6%
1.3 pts worse
|
3.3%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 6.0% · Q3 3.0% · Q4 4.8% · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.6% |
4.8%
2.8 pts worse
|
11.4%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 7.1% · Q3 15.4% · Q4 3.6% · 4Q avg 7.6% |
| Percentage of long-stay residents who lose too much weight | 12.1% |
7.2%
4.9 pts worse
|
5.4%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.6% · Q2 16.7% · Q3 11.5% · Q4 1.7% · 4Q avg 12.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 31.9% |
21.6%
10.3 pts worse
|
19.6%
12.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.5% · Q2 32.7% · Q3 29.8% · Q4 27.1% · 4Q avg 31.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.5% |
15.0%
1.5 pts worse
|
16.7%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.7% · Q2 14.6% · Q3 19.2% · Q4 18.2% · 4Q avg 16.5% · 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 | 31.8% |
21.5%
10.3 pts worse
|
16.3%
15.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 55.4% · Q2 34.1% · Q3 25.3% · Q4 8.8% · 4Q avg 31.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.5% |
16.8%
0.3 pts better
|
14.9%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.3% · Q2 12.8% · Q3 2.1% · Q4 9.6% · 4Q avg 16.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
0.9%
0.2 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 1.5% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
2.6%
1.8 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 0.0% · Q4 1.6% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.1% |
21.2%
0.9 pts worse
|
19.8%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.8% · Q2 21.3% · Q3 24.3% · Q4 20.1% · 4Q avg 22.1% |
| Percentage of long-stay residents with pressure ulcers | 8.0% |
6.0%
2 pts worse
|
5.1%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 8.4% · Q3 9.6% · Q4 8.1% · 4Q avg 8.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 35.3% |
79.9%
44.6 pts worse
|
81.7%
46.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 43.2% · Q2 49.5% · Q3 33.3% · Q4 15.7% · 4Q avg 35.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 8.4% |
13.2%
4.8 pts better
|
12.0%
3.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 8.4% · Observed 8.2% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.5%
1 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 57.5% |
78.1%
20.6 pts worse
|
79.7%
22.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 57.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.1% |
22.9%
1.8 pts better
|
23.9%
2.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.1% · Observed 18.0% · Expected 20.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-02 · Fire 2022-07-29
7 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-07-29 · Fire 2021-03-19
11 health deficiencies
Top issue: Pharmacy Service (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
2024-02-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-29
D · Potential for more than minimal harm
2024-02-02
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-03-29
D · Potential for more than minimal harm
2024-02-02
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-03-29
F · Potential for more than minimal harm
2022-07-29
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-09-16
D · Potential for more than minimal harm
2022-07-29
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-09-16
Inspection history
Recent health citations
G · Actual harm
2025-12-12
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.
Not marked corrected
G · Actual harm
2025-06-02
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-06-20
F · Potential for more than minimal harm
2025-06-02
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 2025-06-20
E · Potential for more than minimal harm
2025-06-02
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-06-20
E · Potential for more than minimal harm
2025-06-02
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 2025-06-20
E · Potential for more than minimal harm
2025-06-02
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-06-20
E · Potential for more than minimal harm
2025-06-02
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-06-20
E · Potential for more than minimal harm
2025-06-02
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2025-06-20
E · Potential for more than minimal harm
2025-06-02
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-06-02
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-06-02
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 2025-06-20
D · Potential for more than minimal harm
2025-06-02
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-06-02
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 2025-06-20
D · Potential for more than minimal harm
2025-06-02
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-06-02
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-06-02
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 2025-06-20
D · Potential for more than minimal harm
2025-06-02
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-06-02
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 2025-06-20
D · Potential for more than minimal harm
2025-06-02
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2025-06-20
C · Minimal harm
2025-06-02
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-06-09
E · Potential for more than minimal harm
2025-03-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-06-02
D · Potential for more than minimal harm
2025-03-27
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-06-20
D · Potential for more than minimal harm
2025-03-27
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-06-02
D · Potential for more than minimal harm
2025-03-27
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 2025-06-20
E · Potential for more than minimal harm
2024-02-02
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2022-12-20
E · Potential for more than minimal harm
2024-02-02
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-02-29
E · Potential for more than minimal harm
2024-02-02
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 2024-02-29
D · Potential for more than minimal harm
2024-02-02
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2024-02-29
D · Potential for more than minimal harm
2024-02-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-02-29
B · Minimal harm
2024-02-02
F551 · Resident Rights Deficiencies
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2024-02-29
B · Minimal harm
2024-02-02
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-02-29
E · Potential for more than minimal harm
2022-07-29
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-08-31
D · Potential for more than minimal harm
2022-07-29
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2022-08-31
D · Potential for more than minimal harm
2022-07-29
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-08-31
D · Potential for more than minimal harm
2022-07-29
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-08-31
D · Potential for more than minimal harm
2022-07-29
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 2022-08-31
D · Potential for more than minimal harm
2022-07-29
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-08-31
D · Potential for more than minimal harm
2022-07-29
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2022-08-31
D · Potential for more than minimal harm
2022-07-29
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-08-31
D · Potential for more than minimal harm
2022-07-29
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-08-31
D · Potential for more than minimal harm
2022-07-29
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 2022-08-31
D · Potential for more than minimal harm
2022-07-29
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 2022-08-31
Penalties and ownership
What sits behind the stars
$13,520
2025-12-12
Fine
Fine · fine $13,520
Fine
$54,080
2025-03-27
Fine
Fine · fine $54,080
Fine
Ownership
Fletcher Holdings I LLC
5% Or Greater Direct Ownership Interest · Organization
Alter, Tzvi
5% Or Greater Indirect Ownership Interest · Individual
Lane, Timothy
Operational/Managerial Control · Individual
West Nc Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
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
#2
The Lodge at Mills River
Mills River, NC
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
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
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