Cycle 1
Health 2025-03-20 · Fire 2025-03-20
5 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Burnsville, NC
Smoky Ridge Health and Rehabilitation
2-star overall rating with 2-star inspections with abuse icon flag with $59,631 in total fines with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
310 Pensacola Road, Burnsville, NC
(828) 682-9759
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
140
Certified beds
Average residents
99
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1989-06-29
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.78
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.49
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
1.89
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.16
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.27
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
2.82
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.54
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.82
CMS adjusted RN staffing hours
Adjusted total hours
3.31
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
24%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
45%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,074
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
60.22
Composite VBP score used to determine payment impact.
Payment multiplier
1.0154
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
10
Baseline 21.36% · Performance 16.26% · Measure score 10 · Achievement 10 · Improvement 9
Healthcare-associated infections
7.73
Baseline 5.03% · Performance 5.52% · Measure score 7.73 · Achievement 7.73 · Improvement 0
Total nurse turnover
6.35
Performance 37.70% · Measure score 6.35 · Achievement 6.35 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 3.37 hours · Performance 3.14 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.48% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 94 · Observed rate 6.38% · Lower 95% interval 6.57% |
| Discharge to community | 52.77% |
50.57%
2.2 pts better
|
No Different than the National Rate · Eligible stays 80 · Observed rate 50% · Lower 95% interval 43.55% |
| Medicare spending per beneficiary | 1.14 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 97.85% |
95.27%
2.6 pts better
|
Numerator 91 · Denominator 93 |
| Falls with major injury | 1.08% |
0.77%
0.3 pts worse
|
Numerator 1 · Denominator 93 |
| Discharge self-care score | 59.42% |
53.69%
5.7 pts better
|
Numerator 41 · Denominator 69 |
| Discharge mobility score | 47.83% |
50.94%
3.1 pts worse
|
Numerator 33 · Denominator 69 |
| Pressure ulcers or injuries, new or worsened | 3.23% |
2.29%
0.9 pts worse
|
Numerator 3 · Denominator 93 · Adjusted rate 3.02% |
| Healthcare-associated infections requiring hospitalization | 5.52% |
7.12%
1.6 pts better
|
No Different than the National Rate · Eligible stays 61 · Observed rate 0% · Lower 95% interval 2.85% |
| Staff COVID-19 vaccination coverage | 5.41% |
8.2%
2.8 pts worse
|
Numerator 6 · Denominator 111 |
| Staff flu vaccination coverage | 18.33% |
42%
23.7 pts worse
|
Numerator 22 · Denominator 120 |
| Discharge function score | 46.38% |
56.45%
10.1 pts worse
|
Numerator 32 · Denominator 69 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 93.94% |
96.28%
2.3 pts worse
|
Numerator 31 · Denominator 33 |
| Resident COVID-19 vaccinations up to date | 19.35% |
25.2%
5.8 pts worse
|
Numerator 12 · Denominator 62 |
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 0.9 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.8
0.3 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.4 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 84.8% |
91.5%
6.7 pts worse
|
93.4%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 79.8% · Q2 84.7% · Q3 84.3% · Q4 90.5% · 4Q avg 84.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 86.0% |
94.1%
8.1 pts worse
|
95.5%
9.5 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 86.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.0% |
3.6%
3.4 pts worse
|
3.3%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q2 8.2% · Q3 6.0% · Q4 9.5% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 26.1% |
4.8%
21.3 pts worse
|
11.4%
14.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 17.6% · Q3 35.1% · Q4 37.8% · 4Q avg 26.1% |
| Percentage of long-stay residents who lose too much weight | 8.1% |
7.2%
0.9 pts worse
|
5.4%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 5.7% · Q3 10.1% · Q4 5.6% · 4Q avg 8.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 32.9% |
21.6%
11.3 pts worse
|
19.6%
13.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.0% · Q2 29.3% · Q3 31.9% · Q4 40.5% · 4Q avg 32.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.5% |
15.0%
8.5 pts worse
|
16.7%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.6% · Q2 20.0% · Q3 25.0% · Q4 27.5% · 4Q avg 23.5% · 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 | 14.6% |
21.5%
6.9 pts better
|
16.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.1% · Q2 16.6% · Q3 11.2% · Q4 15.0% · 4Q avg 14.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.2% |
16.8%
1.4 pts worse
|
14.9%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.1% · Q2 17.6% · Q3 11.3% · Q4 20.5% · 4Q avg 18.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
0.9%
0.2 pts worse
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.0% · Q3 0.0% · Q4 2.1% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.8% |
2.6%
0.8 pts better
|
1.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 5.0% · Q4 1.2% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.8% |
21.2%
5.6 pts worse
|
19.8%
7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.1% · Q2 23.2% · Q3 29.0% · Q4 31.2% · 4Q avg 26.8% |
| Percentage of long-stay residents with pressure ulcers | 6.5% |
6.0%
0.5 pts worse
|
5.1%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 4.9% · Q3 5.7% · Q4 5.8% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 70.1% |
79.9%
9.8 pts worse
|
81.7%
11.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 76.3% · Q2 64.0% · Q3 72.0% · Q4 69.0% · 4Q avg 70.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.0% |
13.2%
4.2 pts better
|
12.0%
3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.0% · Observed 9.2% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 5.2% |
1.5%
3.7 pts worse
|
1.6%
3.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.3% · Q3 8.2% · Q4 8.2% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 53.8% |
78.1%
24.3 pts worse
|
79.7%
25.9 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 53.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.1% |
22.9%
1.2 pts worse
|
23.9%
0.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.1% · Observed 21.1% · Expected 20.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-01 · Fire 2023-12-01
15 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
4 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Cycle 3
Health 2022-06-08 · Fire 2022-06-08
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-03-20
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-06-18
D · Potential for more than minimal harm
2025-03-20
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-06-18
D · Potential for more than minimal harm
2025-03-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-18
F · Potential for more than minimal harm
2024-03-05
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-05-06
D · Potential for more than minimal harm
2023-12-01
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-01-24
D · Potential for more than minimal harm
2023-12-01
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-01-24
D · Potential for more than minimal harm
2023-12-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-01-24
D · Potential for more than minimal harm
2022-06-08
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-08-11
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-03-20
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 2025-04-14
D · Potential for more than minimal harm
2025-03-20
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-12-12
D · Potential for more than minimal harm
2025-03-20
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-04-14
D · Potential for more than minimal harm
2025-03-20
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 2025-04-14
D · Potential for more than minimal harm
2025-03-20
F646 · Resident Assessment and Care Planning Deficiencies
Health
Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.
Corrected 2025-04-14
G · Actual harm
2024-03-20
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.
Corrected 2024-04-05
F · Potential for more than minimal harm
2023-12-01
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 2024-01-01
F · Potential for more than minimal harm
2023-12-01
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-01-01
F · Potential for more than minimal harm
2023-12-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-01-01
E · Potential for more than minimal harm
2023-12-01
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 2024-01-01
E · Potential for more than minimal harm
2023-12-01
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-01-01
E · Potential for more than minimal harm
2023-12-01
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-01-01
E · Potential for more than minimal harm
2023-12-01
F711 · Nursing and Physician Services Deficiencies
Health
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Corrected 2024-01-01
E · Potential for more than minimal harm
2023-12-01
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 2024-01-01
E · Potential for more than minimal harm
2023-12-01
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2024-01-01
D · Potential for more than minimal harm
2023-12-01
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-01-01
D · Potential for more than minimal harm
2023-12-01
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-01-01
D · Potential for more than minimal harm
2023-12-01
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-01-01
D · Potential for more than minimal harm
2023-12-01
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-01-01
B · Minimal harm
2023-12-01
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-01-01
D · Potential for more than minimal harm
2023-06-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-06-30
D · Potential for more than minimal harm
2022-06-08
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 2022-07-06
Penalties and ownership
What sits behind the stars
$59,631
2024-03-20
Fine
Fine · fine $59,631
Fine
Ownership
Fischer, Dovid
5% Or Greater Direct Ownership Interest · Individual
Lefkowitz, Zev
5% Or Greater Direct Ownership Interest · Individual
Shade, Carla
W-2 Managing Employee · Individual
Nearby options
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#2
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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
#3
Erwin Health Care Center
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1-star overall rating with 2-star inspections with $10,024 in total fines with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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