Cycle 1
Health 2024-12-18 · Fire 2024-12-18
9 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Brevard, NC
The Oaks-Brevard
2-star overall rating with 2-star inspections with $6,936 in total fines with 9 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
300 Morris Road, Brevard, NC
(828) 877-4020
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
110
Certified beds
Average residents
79
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pruitthealth
Operator or chain grouping
Approved since
1994-07-21
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
95 facilities
Chain averages 3 overall / 3 health / 2 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
1.09
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
1.99
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
1.58
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.07
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.71
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.19
CMS adjusted RN staffing hours
Adjusted total hours
3.89
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
18%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
26%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,618
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
48.72
Composite VBP score used to determine payment impact.
Payment multiplier
1.0025
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.98
Baseline 20.20% · Performance 20.05% · Measure score 2.98 · Achievement 2.98 · Improvement 0
Healthcare-associated infections
6.98
Baseline 4.83% · Performance 5.75% · Measure score 6.98 · Achievement 6.98 · Improvement 0
Total nurse turnover
8.19
Baseline 50.77% · Performance 30.19% · Measure score 8.19 · Achievement 8.19 · Improvement 7.44
Adjusted total nurse staffing
1.33
Baseline 2.66 hours · Performance 3.23 hours · Measure score 1.33 · Achievement 0.55 · Improvement 1.33
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13.16% |
10.72%
2.4 pts worse
|
No Different than the National Rate · Eligible stays 114 · Observed rate 17.54% · Lower 95% interval 9.18% |
| Discharge to community | 48.74% |
50.57%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 87 · Observed rate 41.38% · Lower 95% interval 38.47% |
| Medicare spending per beneficiary | 0.78 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 95.38% |
95.27%
0.1 pts better
|
Numerator 62 · Denominator 65 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 65 |
| Discharge self-care score | 48.94% |
53.69%
4.8 pts worse
|
Numerator 23 · Denominator 47 |
| Discharge mobility score | 44.68% |
50.94%
6.3 pts worse
|
Numerator 21 · Denominator 47 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 65 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.75% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 60 · Observed rate 1.67% · Lower 95% interval 3.19% |
| Staff COVID-19 vaccination coverage | 0.96% |
8.2%
7.2 pts worse
|
Numerator 1 · Denominator 104 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 55.32% |
56.45%
1.1 pts worse
|
Numerator 26 · Denominator 47 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 97.37% |
96.28%
1.1 pts better
|
Numerator 37 · Denominator 38 |
| Resident COVID-19 vaccinations up to date | 12.9% |
25.2%
12.3 pts worse
|
Numerator 4 · Denominator 31 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
1.8
0.1 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.8 · Expected 2.0 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
1.8
0.5 pts worse
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.8 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.4% |
91.5%
4.9 pts better
|
93.4%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 95.1% · Q3 96.7% · Q4 93.5% · 4Q avg 96.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 88.6% |
94.1%
5.5 pts worse
|
95.5%
6.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 88.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.0% |
3.6%
0.4 pts worse
|
3.3%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 3.3% · Q3 6.7% · Q4 4.8% · 4Q avg 4.0% · 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 | 7.0% |
7.2%
0.2 pts better
|
5.4%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 7.4% · Q3 3.8% · Q4 7.4% · 4Q avg 7.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.2% |
21.6%
2.6 pts worse
|
19.6%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.4% · Q2 22.2% · Q3 22.6% · Q4 31.5% · 4Q avg 24.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.9% |
15.0%
5.9 pts worse
|
16.7%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.9% · Q2 24.4% · Q3 25.6% · Q4 19.1% · 4Q avg 20.9% · 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 | 18.5% |
21.5%
3 pts better
|
16.3%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.9% · Q2 29.2% · Q3 10.7% · Q4 12.0% · 4Q avg 18.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.6% |
16.8%
6.8 pts worse
|
14.9%
8.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.6% · Q2 29.4% · Q3 29.4% · Q4 15.7% · 4Q avg 23.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.6% |
0.9%
0.7 pts worse
|
1.0%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 2.5% · Q3 1.4% · Q4 1.2% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
2.6%
1 pts better
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 1.7% · Q4 3.2% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.0% |
21.2%
2.8 pts worse
|
19.8%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.9% · Q2 15.6% · Q3 22.1% · Q4 26.1% · 4Q avg 24.0% |
| Percentage of long-stay residents with pressure ulcers | 6.0% |
6.0%
About the same
|
5.1%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 8.3% · Q3 1.6% · Q4 6.7% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.3% |
79.9%
9.4 pts better
|
81.7%
7.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 87.8% · Q3 85.4% · Q4 84.9% · 4Q avg 89.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.0% |
13.2%
2.8 pts worse
|
12.0%
4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.0% · Observed 17.7% · Expected 12.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.5%
1 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.5% |
78.1%
15.4 pts better
|
79.7%
13.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 13.8% |
22.9%
9.1 pts better
|
23.9%
10.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 13.8% · Observed 14.5% · Expected 25.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-08-17 · Fire 2023-08-17
14 health deficiencies
Top issue: Resident Rights (4 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2022-01-07 · Fire 2022-01-07
8 health deficiencies
Top issue: Resident Rights (4 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-18
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 2025-04-27
F · Potential for more than minimal harm
2024-12-18
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 2025-04-27
F · Potential for more than minimal harm
2024-12-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-04-27
F · Potential for more than minimal harm
2024-12-18
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-04-27
E · Potential for more than minimal harm
2024-12-18
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-04-27
E · Potential for more than minimal harm
2024-12-18
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-04-27
D · Potential for more than minimal harm
2024-12-18
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-27
D · Potential for more than minimal harm
2024-12-18
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-04-27
D · Potential for more than minimal harm
2024-12-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-27
D · Potential for more than minimal harm
2023-08-17
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 2023-10-06
D · Potential for more than minimal harm
2023-08-17
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 2023-10-06
D · Potential for more than minimal harm
2023-08-17
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-08-17
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-08-17
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-08-17
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-10-06
D · Potential for more than minimal harm
2023-08-17
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-10-06
F · Potential for more than minimal harm
2022-01-07
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-03-16
D · Potential for more than minimal harm
2022-01-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-03-16
Inspection history
Recent health citations
F · Potential for more than minimal harm
2024-12-18
F680 · Quality of Life and Care Deficiencies
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2025-01-16
E · Potential for more than minimal harm
2024-12-18
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-01-16
E · Potential for more than minimal harm
2024-12-18
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-01-16
D · Potential for more than minimal harm
2024-12-18
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-01-16
D · Potential for more than minimal harm
2024-12-18
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-01-16
D · Potential for more than minimal harm
2024-12-18
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-08-07
D · Potential for more than minimal harm
2024-12-18
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-01-16
D · Potential for more than minimal harm
2024-12-18
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-01-16
D · Potential for more than minimal harm
2024-12-18
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 2025-01-16
E · Potential for more than minimal harm
2023-08-17
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 2023-09-06
E · Potential for more than minimal harm
2023-08-17
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 2023-09-06
E · Potential for more than minimal harm
2023-08-17
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 2023-09-06
D · Potential for more than minimal harm
2023-08-17
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2023-09-06
D · Potential for more than minimal harm
2023-08-17
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 2023-09-06
D · Potential for more than minimal harm
2023-08-17
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-09-06
D · Potential for more than minimal harm
2023-08-17
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-09-06
D · Potential for more than minimal harm
2023-08-17
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 2023-09-06
D · Potential for more than minimal harm
2023-08-17
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 2023-09-06
D · Potential for more than minimal harm
2023-08-17
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 2023-07-27
D · Potential for more than minimal harm
2023-08-17
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2023-09-06
D · Potential for more than minimal harm
2023-08-17
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-09-06
D · Potential for more than minimal harm
2023-08-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-09-06
B · Minimal harm
2023-08-17
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-09-06
E · Potential for more than minimal harm
2022-01-07
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2022-02-02
E · Potential for more than minimal harm
2022-01-07
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 2022-02-02
E · Potential for more than minimal harm
2022-01-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-02-02
D · Potential for more than minimal harm
2022-01-07
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2022-02-02
D · Potential for more than minimal harm
2022-01-07
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 2022-02-02
D · Potential for more than minimal harm
2022-01-07
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2022-02-02
D · Potential for more than minimal harm
2022-01-07
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-02-02
B · Minimal harm
2022-01-07
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-02-02
Penalties and ownership
What sits behind the stars
$6,936
2024-12-18
Fine
Fine · fine $6,936
Fine
Ownership
Belue, Jason
Operational/Managerial Control · Individual
Holl, Blair
Operational/Managerial Control · Individual
Pruitt, Neil
Operational/Managerial Control · Individual
Pruitt, Neil
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Transylvania Regional Hospital
Brevard, NC
5-star overall rating with 4-star inspections with $12,415 in total fines with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Sapphire Ridge Health and Rehabilitation
Brevard, NC
1-star overall rating with 2-star inspections with $22,568 in total fines with 12 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
The Greens at Hendersonville
Hendersonville, NC
3-star overall rating with 3-star inspections with $106,208 in total fines with 2 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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