Brevard, NC

Transylvania Regional Hospital

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

260 Hospital Drive, Brevard, NC

(828) 883-5156

Compare this facility

Overall

5 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

5 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

10

Certified beds

Average residents

6

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Hca Healthcare

Operator or chain grouping

Approved since

1997-05-29

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

3 facilities

Chain averages 4 overall / 4 health / 3 staffing / 4 quality stars

Changed ownership

No

Within the last 12 months

Family council

No

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Hospital-based

Yes

CMS reports the provider resides in a hospital

Staffing

Hours and turnover

RN hours / resident day

3.42

Registered nurse staffing · state 0.59 · national 0.68

LPN hours / resident day

0.78

Licensed practical nurse staffing · state 0.87 · national 0.87

Aide hours / resident day

3.80

Nurse aide staffing · state 2.33 · national 2.35

Total nurse hours

8.01

All reported nurse hours · state 3.78 · national 3.89

Licensed hours

4.21

RN + LPN hours · state 1.45 · national 1.54

Weekend hours

7.66

Weekend nurse staffing · state 3.34 · national 3.43

Weekend RN hours

3.55

Weekend registered nurse coverage · state 0.38 · national 0.47

Physical therapist

0.33

Reported PT staffing · state 0.09 · national 0.07

Adjusted RN hours

3.30

CMS adjusted RN staffing hours

Adjusted total hours

7.71

CMS adjusted total nurse staffing hours

Case-mix index

1.42

Higher values indicate more complex resident acuity

RN turnover

20%

Annual RN turnover · state 48% · national 45%

Total nurse turnover

27%

Annual nurse turnover · state 50% · national 46%

SNF VBP

Value-based purchasing

Program rank

5,173

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

37.13

Composite VBP score used to determine payment impact.

Payment multiplier

0.9904

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

2.43

Baseline 19.38% · Performance 20.31% · Measure score 2.43 · Achievement 2.43 · Improvement 0

Healthcare-associated infections

4.72

Baseline 5.61% · Performance 6.42% · Measure score 4.72 · Achievement 4.72 · Improvement 0

Total nurse turnover

3.99

Performance 47.37% · Measure score 3.99 · Achievement 3.99 · This facility did not have sufficient data to calculate a baseline period measure result.

Adjusted total nurse staffing

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.25%	10.72% 0.5 pts worse	No Different than the National Rate · Eligible stays 94 · Observed rate 8.51% · Lower 95% interval 7.31%
Discharge to community	68%	50.57% 17.4 pts better	Better than the National Rate · Eligible stays 91 · Observed rate 75.82% · Lower 95% interval 59.84%
Medicare spending per beneficiary	0.57	1.02 0.5 pts better
Drug regimen review with follow-up	Not Available	95.27%	Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly.
Falls with major injury	Not Available	0.77%	Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly.
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report.
Pressure ulcers or injuries, new or worsened	Not Available	2.29%	Numerator Not Available · Denominator 1 · Adjusted rate Not Available · Too few residents or stays to report publicly.
Healthcare-associated infections requiring hospitalization	6.42%	7.12% 0.7 pts better	No Different than the National Rate · Eligible stays 51 · Observed rate 1.96% · Lower 95% interval 2.99%
Staff COVID-19 vaccination coverage	5.26%	8.2% 2.9 pts worse	Numerator 1 · Denominator 19
Staff flu vaccination coverage	76.1%	42% 34.1 pts better	Numerator 191 · Denominator 251
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	96.7%	79.9% 16.8 pts better	81.7% 15 pts better	Short Stay · 2024Q4-2025Q3 · Q1 96.9% · Q2 95.9% · Q3 97.0% · Q4 97.1% · 4Q avg 96.7%
Percentage of short-stay residents who had an outpatient emergency department visit	15.0%	13.2% 1.8 pts worse	12.0% 3 pts worse	Short Stay · 20240701-20250630 · Adjusted 15.0% · Observed 13.0% · Expected 9.6% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.7%	1.5% 0.8 pts better	1.6% 0.9 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 3.4% · 4Q avg 0.7% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	85.9%	78.1% 7.8 pts better	79.7% 6.2 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 85.9%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	23.3%	22.9% 0.4 pts worse	23.9% 0.6 pts better	Short Stay · 20240701-20250630 · Adjusted 23.3% · Observed 14.8% · Expected 15.2% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-11-25 · Fire 2024-09-25

2 health deficiencies

Top issue: Nutrition and Dietary (1 deficiency)

3 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 2 Health 2024-09-25 · Fire 2023-06-20

2 health deficiencies

Top issue: Infection Control (1 deficiency)

2 fire-safety deficiencies

Top issue: Miscellaneous (1 deficiency)

Cycle 3 Health 2023-06-20 · Fire 2021-11-24

1 health deficiencies

Top issue: Administration (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 2024-09-25

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2024-11-26

D · Potential for more than minimal harm 2024-09-25

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2024-11-26

D · Potential for more than minimal harm 2024-09-25

K754 · Miscellaneous Deficiencies

Fire Safety

Provide properly sized and located linen or trash receptacles.

Corrected 2024-11-26

D · Potential for more than minimal harm 2023-06-20

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-08-31

D · Potential for more than minimal harm 2023-06-20

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 2023-08-31

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-11-25

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 2025-12-24

D · Potential for more than minimal harm 2025-11-25

F554 · Resident Rights Deficiencies

Health

Allow residents to self-administer drugs if determined clinically appropriate.

Corrected 2026-01-01

F · Potential for more than minimal harm 2024-09-25

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-10-28

E · Potential for more than minimal harm 2024-09-25

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 2024-10-28

E · Potential for more than minimal harm 2023-06-20

F868 · Administration Deficiencies

Health

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Corrected 2023-08-22

Penalties and ownership

What sits behind the stars

$6,207 2023-06-20

Fine

Fine · fine $6,207

Fine

$6,208 2023-06-20

Fine

Fine · fine $6,208

Fine

Ownership

Mh Master Holding Lllp

5% Or Greater Direct Ownership Interest · Organization

99% 2 facilities 2019-02-01

Frisco Inc