Cycle 1
Health 2026-02-11 · Fire 2024-11-15
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Mars Hill, NC
Madison Health and Rehabilitation
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
345 Manor Road, Mars Hill, NC
(828) 689-5200
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
88
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Sanstone Health & Rehabilitation
Operator or chain grouping
Approved since
1981-05-25
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
0.74
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.52
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.25
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.51
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.26
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
2.59
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.42
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.78
CMS adjusted RN staffing hours
Adjusted total hours
3.72
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
35%
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
7,111
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.71
Composite VBP score used to determine payment impact.
Payment multiplier
0.9861
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.82
Baseline 16.36% · Performance 18.73% · Measure score 5.82 · Achievement 5.82 · Improvement 0
Healthcare-associated infections
0
Baseline 6.29% · Performance 9.77% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
4.80
Baseline 48.05% · Performance 44.05% · Measure score 4.80 · Achievement 4.80 · Improvement 1.23
Adjusted total nurse staffing
1.66
Baseline 2.49 hours · Performance 3.20 hours · Measure score 1.66 · Achievement 0 · Improvement 1.66
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.85% |
10.72%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 123 · Observed rate 13.01% · Lower 95% interval 8.42% |
| Discharge to community | 47% |
50.57%
3.6 pts worse
|
No Different than the National Rate · Eligible stays 97 · Observed rate 46.39% · Lower 95% interval 39.83% |
| Medicare spending per beneficiary | 1.16 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 98 · Denominator 98 |
| Falls with major injury | 2.04% |
0.77%
1.3 pts worse
|
Numerator 2 · Denominator 98 |
| Discharge self-care score | 52% |
53.69%
1.7 pts worse
|
Numerator 39 · Denominator 75 |
| Discharge mobility score | 46.67% |
50.94%
4.3 pts worse
|
Numerator 35 · Denominator 75 |
| Pressure ulcers or injuries, new or worsened | 1.02% |
2.29%
1.3 pts better
|
Numerator 1 · Denominator 98 · Adjusted rate 0.91% |
| Healthcare-associated infections requiring hospitalization | 9.77% |
7.12%
2.6 pts worse
|
No Different than the National Rate · Eligible stays 97 · Observed rate 12.37% · Lower 95% interval 5.99% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 118 |
| Staff flu vaccination coverage | 4.03% |
42%
38 pts worse
|
Numerator 5 · Denominator 124 |
| Discharge function score | 69.33% |
56.45%
12.9 pts better
|
Numerator 52 · Denominator 75 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 50 · Denominator 50 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 16.67% |
25.2%
8.5 pts worse
|
Numerator 8 · Denominator 48 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
1.8
0.6 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 1.7 · Expected 1.4 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.8
0.9 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.7 · Expected 1.3 · 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 | 100.0% |
94.1%
5.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.8% |
3.6%
0.2 pts worse
|
3.3%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 5.1% · Q3 3.7% · Q4 2.5% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 30.8% |
4.8%
26 pts worse
|
11.4%
19.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 43.7% · Q2 34.2% · Q3 19.7% · Q4 26.3% · 4Q avg 30.8% |
| Percentage of long-stay residents who lose too much weight | 1.0% |
7.2%
6.2 pts better
|
5.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 1.3% · Q4 1.4% · 4Q avg 1.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 25.5% |
21.6%
3.9 pts worse
|
19.6%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 23.3% · Q3 27.3% · Q4 29.3% · 4Q avg 25.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 2.1% |
15.0%
12.9 pts better
|
16.7%
14.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.9% · Q2 1.6% · Q3 1.6% · Q4 3.6% · 4Q avg 2.1% · 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 | 8.1% |
21.5%
13.4 pts better
|
16.3%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 5.6% · Q3 8.5% · Q4 11.3% · 4Q avg 8.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.2% |
16.8%
6.6 pts better
|
14.9%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 7.7% · Q3 5.7% · Q4 17.6% · 4Q avg 10.2% · 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 | 0.6% |
2.6%
2 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.0% · Q4 1.3% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.8% |
21.2%
0.6 pts worse
|
19.8%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.4% · Q2 27.9% · Q3 15.2% · Q4 17.6% · 4Q avg 21.8% |
| Percentage of long-stay residents with pressure ulcers | 1.5% |
6.0%
4.5 pts better
|
5.1%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 0.0% · Q3 3.0% · Q4 1.6% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.1% |
79.9%
18.2 pts better
|
81.7%
16.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.8% · Q2 97.0% · Q3 98.5% · Q4 100.0% · 4Q avg 98.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 6.9% |
13.2%
6.3 pts better
|
12.0%
5.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 6.9% · Observed 6.1% · Expected 9.8% · 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 | 92.6% |
78.1%
14.5 pts better
|
79.7%
12.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.8% |
22.9%
4.9 pts worse
|
23.9%
3.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.8% · Observed 27.3% · Expected 23.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-11-15 · Fire 2023-08-30
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
9 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Cycle 3
Health 2023-08-30 · Fire 2022-02-18
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-11-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-01-01
F · Potential for more than minimal harm
2023-08-30
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-12-23
F · Potential for more than minimal harm
2023-08-30
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-12-23
D · Potential for more than minimal harm
2023-08-30
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-12-23
D · Potential for more than minimal harm
2023-08-30
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 2023-12-23
D · Potential for more than minimal harm
2023-08-30
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-12-23
D · Potential for more than minimal harm
2023-08-30
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-12-23
D · Potential for more than minimal harm
2023-08-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-23
D · Potential for more than minimal harm
2023-08-30
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-12-23
D · Potential for more than minimal harm
2023-08-30
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-12-23
F · Potential for more than minimal harm
2022-02-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-04-08
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-02-11
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.
Not marked corrected
G · Actual harm
2025-08-27
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.
Not marked corrected
E · Potential for more than minimal harm
2024-11-15
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 2024-11-16
D · Potential for more than minimal harm
2023-08-30
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-09-22
D · Potential for more than minimal harm
2023-08-30
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-09-22
Penalties and ownership
What sits behind the stars
$14,015
2025-08-27
Fine
Fine · fine $14,015
Fine
Ownership
Ardent Health And Rehabilitation Co
Operational/Managerial Control · Organization
Madison Healthcare Properties, LLC
5% Or Greater Mortgage Interest · Organization
Niebes, Haley
W-2 Managing Employee · Individual
Sprenger, Christopher
5% Or Greater Direct Ownership Interest · Individual
Nearby options
Other facilities in reach
#1
Elderberry Health Care
Marshall, NC
3-star overall rating with 3-star inspections with 3 recent health deficiencies with 9 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
Bear Mountain Health and Rehabilitation
Asheville, NC
3-star overall rating with 3-star inspections with $11,170 in total fines with 8 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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