6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Andrews, NC
2-star overall rating with 2-star inspections with $9,770 in total fines with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
551 Kent Street, Andrews, NC
(828) 321-3075
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
Beds
76
Certified beds
Average residents
56
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Avardis Health
Operator or chain grouping
Approved since
1992-10-15
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
RN hours / resident day
0.97
Registered nurse staffing
LPN hours / resident day
0.37
Licensed practical nurse staffing
Aide hours / resident day
2.02
Nurse aide staffing
Weekend hours
3.01
Weekend nurse staffing
RN turnover
31%
Annual RN turnover
Total nurse turnover
42%
Annual nurse turnover
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.8
About the same
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.0 |
1.8
1.2 pts worse
|
1.8
1.2 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.2% |
91.5%
6.7 pts better
|
93.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.1%
5.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.4% |
3.6%
0.8 pts worse
|
3.3%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 10.2% |
4.8%
5.4 pts worse
|
11.4%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 6.3% |
7.2%
0.9 pts better
|
5.4%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.5% |
21.6%
5.9 pts worse
|
19.6%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 16.0% |
15.0%
1 pts worse
|
16.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 10.5% |
21.5%
11 pts better
|
16.3%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.9% |
16.8%
5.9 pts better
|
14.9%
4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
0.9%
0.4 pts worse
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 1.4% |
2.6%
1.2 pts better
|
1.7%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.1% |
21.2%
6.1 pts better
|
19.8%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 5.9% |
6.0%
0.1 pts better
|
5.1%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 95.3% |
79.9%
15.4 pts better
|
81.7%
13.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.4% |
13.2%
1.2 pts worse
|
12.0%
2.4 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.5%
0.3 pts better
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 83.7% |
78.1%
5.6 pts better
|
79.7%
4 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 14.3% |
22.9%
8.6 pts better
|
23.9%
9.6 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Top issue: Pharmacy Service (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Top issue: Resident Rights (5 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Resident Assessment and Care Planning (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
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 2025-05-09
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-05-09
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-09
Fire Safety
Use approved construction type or materials.
Corrected 2024-05-15
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-05-15
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 2024-05-15
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-05-15
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-15
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-05-15
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-05-15
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-05-15
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-05-15
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-05-15
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-05-15
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-05-15
Inspection history
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-10
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 2025-04-10
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-04-10
Health
Provide or obtain dental services for each resident.
Corrected 2025-04-10
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 2025-04-10
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-10
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-11-27
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 2023-11-27
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-11-27
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2023-11-27
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-11-27
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-11-27
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 2023-11-27
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-11-27
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-11-27
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-11-27
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 2023-11-27
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-11-27
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-27
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-11-27
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-04-25
Penalties and ownership
Fine · fine $3,465
Fine
Fine · fine $6,305
Fine
5% Or Greater Security Interest · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
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