Cycle 1
Health 2025-06-03 · Fire 2024-03-14
1 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Mills River, NC
The Lodge at Mills River
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
5593 Old Haywood Road, Mills River, NC
(828) 684-4857
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
50
Certified beds
Average residents
45
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Sanstone Health & Rehabilitation
Operator or chain grouping
Approved since
1986-12-19
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
0.88
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.82
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
1.87
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.56
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.69
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
2.94
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
0.13
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.69
CMS adjusted RN staffing hours
Adjusted total hours
2.82
CMS adjusted total nurse staffing hours
Case-mix index
1.73
Higher values indicate more complex resident acuity
RN turnover
64%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,890
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
47.13
Composite VBP score used to determine payment impact.
Payment multiplier
1.0006
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.77
Baseline 16.73% · Performance 18.30% · Measure score 6.77 · Achievement 6.77 · Improvement 0
Healthcare-associated infections
10
Baseline 4.92% · Performance 4.95% · Measure score 10 · Achievement 10 · Improvement 0
Total nurse turnover
2.09
Baseline 66.00% · Performance 55.36% · Measure score 2.09 · Achievement 2.04 · Improvement 2.09
Adjusted total nurse staffing
0
Baseline 3.11 hours · Performance 2.63 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.6% |
10.72%
1.1 pts better
|
No Different than the National Rate · Eligible stays 528 · Observed rate 7.2% · Lower 95% interval 7.31% |
| Discharge to community | 67.97% |
50.57%
17.4 pts better
|
Better than the National Rate · Eligible stays 568 · Observed rate 71.65% · Lower 95% interval 64.59% |
| Medicare spending per beneficiary | 1.14 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 297 · Denominator 297 |
| Falls with major injury | 1.68% |
0.77%
0.9 pts worse
|
Numerator 5 · Denominator 297 |
| Discharge self-care score | 84.12% |
53.69%
30.4 pts better
|
Numerator 196 · Denominator 233 |
| Discharge mobility score | 70.82% |
50.94%
19.9 pts better
|
Numerator 165 · Denominator 233 |
| Pressure ulcers or injuries, new or worsened | 0.67% |
2.29%
1.6 pts better
|
Numerator 2 · Denominator 297 · Adjusted rate 0.86% |
| Healthcare-associated infections requiring hospitalization | 4.95% |
7.12%
2.2 pts better
|
No Different than the National Rate · Eligible stays 328 · Observed rate 2.74% · Lower 95% interval 2.89% |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | 5.41% |
42%
36.6 pts worse
|
Numerator 4 · Denominator 74 |
| Discharge function score | 88.84% |
56.45%
32.4 pts better
|
Numerator 207 · Denominator 233 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 254 · Denominator 254 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 28 · Denominator 28 |
| Resident COVID-19 vaccinations up to date | 25.34% |
25.2%
0.1 pts better
|
Numerator 37 · Denominator 146 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| 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 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 7.1% |
3.6%
3.5 pts worse
|
3.3%
3.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.8% |
4.8%
1 pts better
|
11.4%
7.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.8% |
| Percentage of long-stay residents who lose too much weight | 4.3% |
7.2%
2.9 pts better
|
5.4%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.6% |
21.6%
7 pts better
|
19.6%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.0% |
15.0%
5 pts better
|
16.7%
6.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 10.0% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 11.8% |
21.5%
9.7 pts better
|
16.3%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.3% |
16.8%
8.5 pts better
|
14.9%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.3% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.7% |
2.6%
1.1 pts worse
|
1.7%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.6% |
21.2%
3.6 pts better
|
19.8%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.6% |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
6.0%
6 pts better
|
5.1%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.9% |
79.9%
18 pts better
|
81.7%
16.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.6% · Q2 97.8% · Q3 98.9% · Q4 100.0% · 4Q avg 97.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.2% |
13.2%
4 pts worse
|
12.0%
5.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.2% · Observed 13.1% · Expected 8.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.5%
0.5 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.4% · Q3 0.7% · Q4 0.6% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.8% |
78.1%
19.7 pts better
|
79.7%
18.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.3% |
22.9%
2.6 pts better
|
23.9%
3.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.3% · Observed 14.2% · Expected 16.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-14 · Fire 2022-12-01
0 health deficiencies
No concentrated health issue counts in this cycle.
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Cycle 3
Health 2022-12-01 · Fire 2021-03-04
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-03-14
K700 · Miscellaneous Deficiencies
Fire Safety
Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.
Corrected 2024-05-28
D · Potential for more than minimal harm
2024-03-14
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-05-28
F · Potential for more than minimal harm
2022-12-01
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-03-31
F · Potential for more than minimal harm
2022-12-01
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-03-31
D · Potential for more than minimal harm
2022-12-01
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-03-31
D · Potential for more than minimal harm
2022-12-01
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-03-31
D · Potential for more than minimal harm
2022-12-01
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2023-03-31
D · Potential for more than minimal harm
2022-12-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-31
Inspection history
Recent health citations
B · Minimal harm
2025-06-03
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-06-04
J · Immediate jeopardy
2022-12-01
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 2022-09-15
E · Potential for more than minimal harm
2022-12-01
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 2022-12-26
D · Potential for more than minimal harm
2022-12-01
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2022-12-26
D · Potential for more than minimal harm
2022-12-01
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-12-26
D · Potential for more than minimal harm
2022-12-01
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-12-26
Penalties and ownership
What sits behind the stars
Ownership
Ardent Health And Rehabilitation Co
5% Or Greater Direct Ownership Interest · Organization
Henderson-Beystone Healthcare Properties, LLC
5% Or Greater Direct Ownership Interest · Organization
Sprenger, Andrew
W-2 Managing Employee · Individual
Sprenger, Christopher
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Fletcher Rehabilitation and Healthcare Center
Fletcher, NC
1-star overall rating with 1-star inspections with abuse icon flag with $67,600 in total fines with 24 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Biltmore Haven Nursing and Rehabilitation
Arden, NC
1-star overall rating with 1-star inspections with Special Focus status with $172,134 in total fines with 17 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Orchard Valley Health and Rehabilitation
Hendersonville, NC
1-star overall rating with 1-star inspections with $16,452 in total fines with 28 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
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