Cycle 1
Health 2025-12-03 · Fire 2024-09-06
1 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Rutherfordton, NC
Oak Grove Healthcare
4-star overall rating with 5-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
518 Old US 221 Highway, Rutherfordton, NC
(828) 287-7655
Overall
4 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
53
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Avardis Health
Operator or chain grouping
Approved since
1994-09-08
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
14 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
0.32
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.83
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
1.79
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
2.94
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.15
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
2.45
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.20
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.35
CMS adjusted RN staffing hours
Adjusted total hours
3.18
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
78%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,952
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.20
Composite VBP score used to determine payment impact.
Payment multiplier
0.9837
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.56
Baseline 21.31% · Performance 19.78% · Measure score 3.56 · Achievement 3.56 · Improvement 3.07
Healthcare-associated infections
4.04
Baseline 6.22% · Performance 6.63% · Measure score 4.04 · Achievement 4.04 · Improvement 0
Total nurse turnover
2.47
Baseline 48.89% · Performance 53.57% · Measure score 2.47 · Achievement 2.47 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.1 hours · Performance 3.08 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.43% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 82 · Observed rate 8.54% · Lower 95% interval 7.58% |
| Discharge to community | 62.35% |
50.57%
11.8 pts better
|
Better than the National Rate · Eligible stays 78 · Observed rate 62.82% · Lower 95% interval 52.81% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 44 · Denominator 44 |
| Falls with major injury | 2.27% |
0.77%
1.5 pts worse
|
Numerator 1 · Denominator 44 |
| Discharge self-care score | 48.28% |
53.69%
5.4 pts worse
|
Numerator 14 · Denominator 29 |
| Discharge mobility score | 20.69% |
50.94%
30.2 pts worse
|
Numerator 6 · Denominator 29 |
| Pressure ulcers or injuries, new or worsened | 6.82% |
2.29%
4.5 pts worse
|
Numerator 3 · Denominator 44 · Adjusted rate 6.09% |
| Healthcare-associated infections requiring hospitalization | 6.63% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 47 · Observed rate 4.26% · Lower 95% interval 3.88% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 64 |
| Staff flu vaccination coverage | 4.76% |
42%
37.2 pts worse
|
Numerator 4 · Denominator 84 |
| Discharge function score | 37.93% |
56.45%
18.5 pts worse
|
Numerator 11 · Denominator 29 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 23 · Denominator 23 |
| Resident COVID-19 vaccinations up to date | 12.5% |
25.2%
12.7 pts worse
|
Numerator 3 · Denominator 24 |
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 0.8 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
1.8
0.2 pts worse
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.7 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.8% |
91.5%
6.3 pts better
|
93.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.8% · Q2 95.7% · Q3 97.9% · Q4 100.0% · 4Q avg 97.8% |
| 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 | 7.7% |
3.6%
4.1 pts worse
|
3.3%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 8.7% · Q3 6.4% · Q4 6.7% · 4Q avg 7.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.8%
4.8 pts better
|
11.4%
11.4 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 who lose too much weight | 7.5% |
7.2%
0.3 pts worse
|
5.4%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 10.3% · Q3 5.1% · Q4 4.8% · 4Q avg 7.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.8% |
21.6%
6.8 pts better
|
19.6%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 15.4% · Q3 15.0% · Q4 16.3% · 4Q avg 14.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.2% |
15.0%
2.8 pts better
|
16.7%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 14.7% · Q3 13.9% · Q4 10.8% · 4Q avg 12.2% · 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 | 21.4% |
21.5%
0.1 pts better
|
16.3%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.9% |
16.8%
4.9 pts better
|
14.9%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.1% · Q2 8.3% · Q3 16.2% · Q4 14.6% · 4Q avg 11.9% · 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 | 3.8% |
2.6%
1.2 pts worse
|
1.7%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 8.7% · Q3 2.1% · Q4 4.5% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.2% |
21.2%
1 pts better
|
19.8%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.3% · Q2 18.1% · Q3 19.2% · Q4 17.4% · 4Q avg 20.2% |
| Percentage of long-stay residents with pressure ulcers | 2.8% |
6.0%
3.2 pts better
|
5.1%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 2.7% · Q3 2.6% · Q4 1.7% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.9% |
79.9%
10 pts better
|
81.7%
8.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 88.0% · Q2 88.6% · Q3 89.6% · Q4 93.8% · 4Q avg 89.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.6% |
13.2%
6.4 pts worse
|
12.0%
7.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 19.6% · Observed 17.9% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.5%
0.3 pts better
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.2% · Q4 2.5% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 84.7% |
78.1%
6.6 pts better
|
79.7%
5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 84.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.9% |
22.9%
2 pts better
|
23.9%
3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.9% · Observed 17.9% · Expected 20.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-06 · Fire 2022-07-13
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2022-07-13 · Fire 2020-12-21
2 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-09-06
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-11-12
D · Potential for more than minimal harm
2024-09-06
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-11-12
D · Potential for more than minimal harm
2022-07-13
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2022-10-17
D · Potential for more than minimal harm
2022-07-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-10-17
D · Potential for more than minimal harm
2022-07-13
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-10-17
C · Minimal harm
2022-07-13
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 2022-10-17
Inspection history
Recent health citations
C · Minimal harm
2025-12-03
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-12-04
D · Potential for more than minimal harm
2024-09-06
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-07-01
D · Potential for more than minimal harm
2024-09-06
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-10-03
D · Potential for more than minimal harm
2022-07-13
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 2022-08-09
D · Potential for more than minimal harm
2022-07-13
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-08-09
Penalties and ownership
What sits behind the stars
Ownership
Rutherfordton Parentco LLC
5% Or Greater Direct Ownership Interest · Organization
Fc Encore Rutherfordton LLC
5% Or Greater Security Interest · Organization
Franklin, Christina
Operational/Managerial Control · Individual
Hainsworth, Jeffrey
Operational/Managerial Control · Individual
Hoback, Tiffany
Operational/Managerial Control · Individual
Jones, Tequilla
Operational/Managerial Control · Individual
Kennedy, Sherry
Operational/Managerial Control · Individual
Ncop Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Nu C Ii Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Nu C Irrevocable Trust
5% Or Greater Indirect Ownership Interest · Organization
Ouh Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Semones, Brandi
Operational/Managerial Control · Individual
Snf Care Centers LLC
5% Or Greater Indirect Ownership Interest · Organization
Snf Mgr LLC
Operational/Managerial Control · Organization
Zenith Holdco Ii LLC
5% Or Greater Indirect Ownership Interest · Organization
Zenith Holdco LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
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
#2
Hilltop Health and Rehabilitation
Rutherfordton, NC
2-star overall rating with 2-star inspections with $25,812 in total fines with 2 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Fair Haven of Forest City, LLC
Forest City, 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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