Cycle 1
Health 2025-09-18 · Fire 2024-09-11
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Flat Rock, NC
Hendersonville Health and Rehabilitation
5-star overall rating with 4-star inspections with 2 fire-safety deficiencies in the latest cycle
104 College Drive, Flat Rock, NC
(828) 693-8600
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
130
Certified beds
Average residents
102
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Sanstone Health & Rehabilitation
Operator or chain grouping
Approved since
1999-06-03
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
17 facilities
Chain averages 4 overall / 4 health / 3 staffing / 4 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
0.54
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.75
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.23
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.52
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.29
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
2.87
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.28
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.54
CMS adjusted RN staffing hours
Adjusted total hours
3.48
CMS adjusted total nurse staffing hours
Case-mix index
1.38
Higher values indicate more complex resident acuity
RN turnover
31%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
37%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
821
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
63.26
Composite VBP score used to determine payment impact.
Payment multiplier
1.0180
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
10
Baseline 16.57% · Performance 16.59% · Measure score 10 · Achievement 10 · Improvement 0
Healthcare-associated infections
7.23
Baseline 5.10% · Performance 5.67% · Measure score 7.23 · Achievement 7.23 · Improvement 0
Total nurse turnover
6.90
Baseline 36.84% · Performance 35.48% · Measure score 6.90 · Achievement 6.90 · Improvement 0.63
Adjusted total nurse staffing
1.18
Baseline 2.87 hours · Performance 3.35 hours · Measure score 1.18 · Achievement 0.97 · Improvement 1.18
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.06% |
10.72%
2.7 pts better
|
No Different than the National Rate · Eligible stays 340 · Observed rate 5.29% · Lower 95% interval 5.82% |
| Discharge to community | 69.68% |
50.57%
19.1 pts better
|
Better than the National Rate · Eligible stays 323 · Observed rate 69.35% · Lower 95% interval 64.92% |
| Medicare spending per beneficiary | 1.15 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 220 · Denominator 220 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 220 |
| Discharge self-care score | 51.11% |
53.69%
2.6 pts worse
|
Numerator 92 · Denominator 180 |
| Discharge mobility score | 49.44% |
50.94%
1.5 pts worse
|
Numerator 89 · Denominator 180 |
| Pressure ulcers or injuries, new or worsened | 1.82% |
2.29%
0.5 pts better
|
Numerator 4 · Denominator 220 · Adjusted rate 2.05% |
| Healthcare-associated infections requiring hospitalization | 5.67% |
7.12%
1.5 pts better
|
No Different than the National Rate · Eligible stays 223 · Observed rate 3.59% · Lower 95% interval 3.47% |
| Staff COVID-19 vaccination coverage | 11.11% |
8.2%
2.9 pts better
|
Numerator 17 · Denominator 153 |
| Staff flu vaccination coverage | 36.23% |
42%
5.8 pts worse
|
Numerator 50 · Denominator 138 |
| Discharge function score | 59.44% |
56.45%
3 pts better
|
Numerator 107 · Denominator 180 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 175 · Denominator 175 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 47.79% |
25.2%
22.6 pts better
|
Numerator 54 · Denominator 113 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.8
0.7 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 1.2 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.8
0.4 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.3 · Expected 1.5 · 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 | 98.7% |
94.1%
4.6 pts better
|
95.5%
3.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.0% |
3.6%
0.6 pts better
|
3.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 4.1% · Q3 2.6% · Q4 3.9% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.0% |
4.8%
2.2 pts worse
|
11.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 4.2% · Q3 8.1% · Q4 10.0% · 4Q avg 7.0% |
| Percentage of long-stay residents who lose too much weight | 0.7% |
7.2%
6.5 pts better
|
5.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.7% · 4Q avg 0.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 31.6% |
21.6%
10 pts worse
|
19.6%
12 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.7% · Q2 30.6% · Q3 33.3% · Q4 32.9% · 4Q avg 31.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.7% |
15.0%
8.3 pts better
|
16.7%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 6.3% · Q3 6.8% · Q4 5.1% · 4Q avg 6.7% · 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 | 14.7% |
21.5%
6.8 pts better
|
16.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.5% · Q2 17.4% · Q3 8.5% · Q4 11.7% · 4Q avg 14.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.7% |
16.8%
3.1 pts better
|
14.9%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 16.2% · Q3 16.4% · Q4 11.0% · 4Q avg 13.7% · 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 | 1.0% |
2.6%
1.6 pts better
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 0.0% · Q4 2.7% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.8% |
21.2%
1.4 pts better
|
19.8%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 14.9% · Q2 27.5% · Q3 21.6% · Q4 15.6% · 4Q avg 19.8% |
| Percentage of long-stay residents with pressure ulcers | 4.4% |
6.0%
1.6 pts better
|
5.1%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 2.8% · Q3 5.2% · Q4 4.0% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.5% |
79.9%
18.6 pts better
|
81.7%
16.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.8% · Q2 100.0% · Q3 98.8% · Q4 96.8% · 4Q avg 98.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.1% |
13.2%
5.9 pts worse
|
12.0%
7.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 19.1% · Observed 16.1% · Expected 9.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.1% |
78.1%
19 pts better
|
79.7%
17.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.5% |
22.9%
5.4 pts better
|
23.9%
6.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.5% · Observed 15.0% · Expected 20.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-11 · Fire 2023-06-16
3 health deficiencies
Top issue: Environmental (1 deficiency)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2023-06-16 · Fire 2021-10-14
8 health deficiencies
Top issue: Resident Rights (4 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-09-11
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-11-12
D · Potential for more than minimal harm
2024-09-11
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-11-12
D · Potential for more than minimal harm
2024-01-25
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2024-03-16
D · Potential for more than minimal harm
2023-06-16
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-08-26
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-09-11
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-09-12
D · Potential for more than minimal harm
2024-09-11
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 2024-09-12
D · Potential for more than minimal harm
2024-09-11
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2024-09-12
E · Potential for more than minimal harm
2023-06-16
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 2023-07-12
E · Potential for more than minimal harm
2023-06-16
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-06-16
D · Potential for more than minimal harm
2023-06-16
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-07-06
D · Potential for more than minimal harm
2023-06-16
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-06-21
D · Potential for more than minimal harm
2023-06-16
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-07-06
D · Potential for more than minimal harm
2023-06-16
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 2023-07-14
D · Potential for more than minimal harm
2023-06-16
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 2023-07-06
D · Potential for more than minimal harm
2023-06-16
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-06-30
Penalties and ownership
What sits behind the stars
Ownership
Bluesky Healthcare Inc
5% Or Greater Direct Ownership Interest · Organization
Bsh Investments LLC
5% Or Greater Direct Ownership Interest · Organization
Flat Rock Management Company
5% Or Greater Direct Ownership Interest · Organization
Hendersonville Physicians And Associates LLC
5% Or Greater Direct Ownership Interest · Organization
Hendersonville Physicians And Associates LLC
5% Or Greater Mortgage Interest · Organization
Hutsenpiller, Wendie
5% Or Greater Direct Ownership Interest · Individual
Malanowski, Kenneth
5% Or Greater Direct Ownership Interest · Individual
Shaker, Hayam
5% Or Greater Direct Ownership Interest · Individual
Sprenger, Christopher
5% Or Greater Direct Ownership Interest · Individual
Sprenger, Christopher
Operational/Managerial Control · Individual
Sprenger, Christopher
Corporate Director · Individual
Sprenger, Nicole
5% Or Greater Direct Ownership Interest · Individual
Sprenger, Tracey
5% Or Greater Direct Ownership Interest · Individual
Sprenger, Tracey
General Partnership Interest · Individual
Nearby options
Other facilities in reach
#1
Carolina Village Inc
Hendersonville, NC
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Life Care Center of Hendersonville
Hendersonville, NC
3-star overall rating with 2-star inspections with $40,986 in total fines with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Valley Hill Health & Rehab Center
Hendersonville, NC
2-star overall rating with 2-star inspections with $58,949 in total fines with 6 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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