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

Compare this facility

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

Staffing

Hours and turnover

RN hours / resident day

0.74

Registered nurse staffing

LPN hours / resident day

0.52

Licensed practical nurse staffing

Aide hours / resident day

2.25

Nurse aide staffing

Weekend hours

2.59

Weekend nurse staffing

RN turnover

35%

Annual RN turnover

Total nurse turnover

39%

Annual nurse turnover

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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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

Survey summary

Recent inspection cycles

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)

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

0% 10 facilities 2010-12-14
Madison Healthcare Properties, LLC

5% Or Greater Mortgage Interest · Organization

0% 1 facilities 2013-10-22
Niebes, Haley

W-2 Managing Employee · Individual

0% 1 facilities 2019-06-01
Sprenger, Christopher

5% Or Greater Direct Ownership Interest · Individual

0% 17 facilities 2010-12-14

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Staffing
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Fines
$0
#2

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Overall
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Health
4 / 5
Staffing
4 / 5
Fines
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#3

Bear Mountain Health and Rehabilitation

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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

Overall
3 / 5
Health
3 / 5
Staffing
2 / 5
Fines
$11,170

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