Cycle 1
Health 2025-04-01 · Fire 2025-04-01
2 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Candler, NC
Pisgah Manor Health Care Center
1-star overall rating with 1-star inspections with $58,516 in total fines with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
104 Holcombe Cove Road, Candler, NC
(828) 667-9851
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
118
Certified beds
Average residents
102
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Liberty Senior Living
Operator or chain grouping
Approved since
1991-07-16
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
35 facilities
Chain averages 3 overall / 3 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
0.64
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.48
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
1.67
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
2.79
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.12
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
2.52
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
0.06
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.61
CMS adjusted RN staffing hours
Adjusted total hours
2.64
CMS adjusted total nurse staffing hours
Case-mix index
1.45
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
50%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,006
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.30
Composite VBP score used to determine payment impact.
Payment multiplier
0.9883
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.85
Baseline 21.87% · Performance 19.77% · Measure score 3.85 · Achievement 3.60 · Improvement 3.85
Healthcare-associated infections
5.65
Baseline 4.55% · Performance 6.15% · Measure score 5.65 · Achievement 5.65 · Improvement 0
Total nurse turnover
4.22
Baseline 45.00% · Performance 46.43% · Measure score 4.22 · Achievement 4.22 · Improvement 0
Adjusted total nurse staffing
0
Baseline 2.68 hours · Performance 2.70 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.08% |
10.72%
0.6 pts better
|
No Different than the National Rate · Eligible stays 198 · Observed rate 10.1% · Lower 95% interval 7.4% |
| Discharge to community | 51.4% |
50.57%
0.8 pts better
|
No Different than the National Rate · Eligible stays 187 · Observed rate 45.99% · Lower 95% interval 42.5% |
| Medicare spending per beneficiary | 0.94 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.05% |
95.27%
2.8 pts better
|
Numerator 151 · Denominator 154 |
| Falls with major injury | 4.55% |
0.77%
3.8 pts worse
|
Numerator 7 · Denominator 154 |
| Discharge self-care score | 50.91% |
53.69%
2.8 pts worse
|
Numerator 56 · Denominator 110 |
| Discharge mobility score | 34.55% |
50.94%
16.4 pts worse
|
Numerator 38 · Denominator 110 |
| Pressure ulcers or injuries, new or worsened | 1.95% |
2.29%
0.3 pts better
|
Numerator 3 · Denominator 154 · Adjusted rate 1.96% |
| Healthcare-associated infections requiring hospitalization | 6.15% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 129 · Observed rate 4.65% · Lower 95% interval 3.69% |
| Staff COVID-19 vaccination coverage | 7.25% |
8.2%
0.9 pts worse
|
Numerator 10 · Denominator 138 |
| Staff flu vaccination coverage | 47.02% |
42%
5 pts better
|
Numerator 71 · Denominator 151 |
| Discharge function score | 43.64% |
56.45%
12.8 pts worse
|
Numerator 48 · Denominator 110 |
| Transfer of health information to provider | 98.44% |
95.95%
2.5 pts better
|
Numerator 63 · Denominator 64 |
| Transfer of health information to patient | 93.48% |
96.28%
2.8 pts worse
|
Numerator 43 · Denominator 46 |
| Resident COVID-19 vaccinations up to date | 23.33% |
25.2%
1.9 pts worse
|
Numerator 21 · Denominator 90 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
1.8
0.5 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.7 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.8
0.6 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.2 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.0% |
91.5%
5.5 pts better
|
93.4%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.1% · Q2 98.8% · Q3 97.7% · Q4 96.3% · 4Q avg 97.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.9% |
94.1%
4.8 pts better
|
95.5%
3.4 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 11.2% |
3.6%
7.6 pts worse
|
3.3%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.9% · Q2 12.5% · Q3 11.6% · Q4 11.0% · 4Q avg 11.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.1% |
4.8%
0.3 pts worse
|
11.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 6.5% · Q3 7.4% · Q4 2.5% · 4Q avg 5.1% |
| Percentage of long-stay residents who lose too much weight | 4.5% |
7.2%
2.7 pts better
|
5.4%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.6% · Q3 4.2% · Q4 8.5% · 4Q avg 4.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.5% |
21.6%
0.9 pts worse
|
19.6%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.7% · Q2 24.2% · Q3 23.3% · Q4 20.8% · 4Q avg 22.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 18.9% |
15.0%
3.9 pts worse
|
16.7%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.4% · Q2 21.2% · Q3 15.3% · Q4 17.5% · 4Q avg 18.9% · 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 | 13.0% |
21.5%
8.5 pts better
|
16.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.6% · Q2 10.0% · Q3 12.6% · Q4 10.2% · 4Q avg 13.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.1% |
16.8%
0.7 pts better
|
14.9%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 15.4% · Q3 15.3% · Q4 21.1% · 4Q avg 16.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.7% |
0.9%
0.8 pts worse
|
1.0%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 2.1% · Q3 2.6% · Q4 0.9% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.3% |
2.6%
1.7 pts worse
|
1.7%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 10.1% · Q3 1.2% · Q4 3.7% · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.2% |
21.2%
6 pts worse
|
19.8%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.5% · Q2 31.9% · Q3 26.1% · Q4 21.5% · 4Q avg 27.2% |
| Percentage of long-stay residents with pressure ulcers | 5.5% |
6.0%
0.5 pts better
|
5.1%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.0% · Q2 7.2% · Q3 2.0% · Q4 4.1% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 86.8% |
79.9%
6.9 pts better
|
81.7%
5.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 87.3% · Q2 81.5% · Q3 86.2% · Q4 91.5% · 4Q avg 86.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.3% |
13.2%
0.9 pts better
|
12.0%
0.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.3% · Observed 10.4% · Expected 9.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.6% |
1.5%
1.1 pts worse
|
1.6%
1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.0% · Q3 1.8% · Q4 4.4% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 81.6% |
78.1%
3.5 pts better
|
79.7%
1.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 81.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 31.2% |
22.9%
8.3 pts worse
|
23.9%
7.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 31.2% · Observed 26.1% · Expected 20.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-06 · Fire 2023-12-06
9 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-06-10 · Fire 2022-06-10
20 health deficiencies
Top issue: Resident Rights (7 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-01
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-05-29
D · Potential for more than minimal harm
2025-04-01
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 2025-05-29
D · Potential for more than minimal harm
2025-04-01
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-29
D · Potential for more than minimal harm
2023-12-06
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-02-14
D · Potential for more than minimal harm
2023-12-06
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-14
D · Potential for more than minimal harm
2022-06-10
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-07-25
D · Potential for more than minimal harm
2022-06-10
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2022-07-25
Inspection history
Recent health citations
L · Immediate jeopardy
2025-04-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-02
E · Potential for more than minimal harm
2025-04-01
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 2025-04-02
E · Potential for more than minimal harm
2023-12-06
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 2024-01-02
E · Potential for more than minimal harm
2023-12-06
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 2024-01-02
E · Potential for more than minimal harm
2023-12-06
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-01-02
D · Potential for more than minimal harm
2023-12-06
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 2024-01-02
D · Potential for more than minimal harm
2023-12-06
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-01-02
D · Potential for more than minimal harm
2023-12-06
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-01-02
D · Potential for more than minimal harm
2023-12-06
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 2024-01-02
D · Potential for more than minimal harm
2023-12-06
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-01-02
D · Potential for more than minimal harm
2023-12-06
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 2024-01-02
H · Actual harm
2022-06-10
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 2022-07-04
H · Actual harm
2022-06-10
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 2022-07-04
F · Potential for more than minimal harm
2022-06-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-07-04
E · Potential for more than minimal harm
2022-06-10
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2022-07-04
E · Potential for more than minimal harm
2022-06-10
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 2022-07-04
E · Potential for more than minimal harm
2022-06-10
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 2022-07-04
D · Potential for more than minimal harm
2022-06-10
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2022-07-04
D · Potential for more than minimal harm
2022-06-10
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-07-04
D · Potential for more than minimal harm
2022-06-10
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 2022-07-04
D · Potential for more than minimal harm
2022-06-10
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2022-07-04
D · Potential for more than minimal harm
2022-06-10
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2022-07-04
D · Potential for more than minimal harm
2022-06-10
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-07-04
D · Potential for more than minimal harm
2022-06-10
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2022-07-04
D · Potential for more than minimal harm
2022-06-10
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 2022-07-04
D · Potential for more than minimal harm
2022-06-10
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-07-04
D · Potential for more than minimal harm
2022-06-10
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-07-04
D · Potential for more than minimal harm
2022-06-10
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-07-04
D · Potential for more than minimal harm
2022-06-10
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2022-07-04
D · Potential for more than minimal harm
2022-06-10
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 2022-07-04
C · Minimal harm
2022-06-10
F888 · Infection Control Deficiencies
Health
Ensure staff are vaccinated for COVID-19
Corrected 2022-07-04
Penalties and ownership
What sits behind the stars
$58,516
2025-04-01
Fine
Fine · fine $58,516
Fine
Ownership
Long Term Care Management Services LLC
5% Or Greater Direct Ownership Interest · Organization
Mcneill, John
5% Or Greater Indirect Ownership Interest · Individual
Mcneill, Ronald
5% Or Greater Indirect Ownership Interest · Individual
Calcutt, Joeseph V
Operational/Managerial Control · Individual
Calcutt, Joeseph V
Corporate Officer · Individual
Grandy, Michelle
Operational/Managerial Control · Individual
Long Term Care Management Services LLC
Operational/Managerial Control · Organization
Mcneill, John
Operational/Managerial Control · Individual
Mcneill, Ronald
Operational/Managerial Control · Individual
Miller, Robert
Corporate Director · Individual
Purifoy, Penny
Operational/Managerial Control · Individual
Purifoy, Penny
Corporate Director · Individual
Wilson, Jeffrey
Operational/Managerial Control · Individual
Wilson, Jeffrey
Corporate Officer · Individual
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