Cycle 1
Health 2025-03-14 · Fire 2025-03-14
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
Valley View Care and Rehabilitation
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
Facility snapshot
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
Chain footprint
14 facilities
Chain averages 2 overall / 2 health / 2 staffing / 3 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
0.97
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.37
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.02
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.36
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.34
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.01
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.47
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.11
CMS adjusted RN staffing hours
Adjusted total hours
3.84
CMS adjusted total nurse staffing hours
Case-mix index
1.20
Higher values indicate more complex resident acuity
RN turnover
31%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
42%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,006
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.06
Composite VBP score used to determine payment impact.
Payment multiplier
0.9863
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.85
Performance 20.57% · Measure score 1.85 · Achievement 1.85 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
2.80
Baseline 7.86% · Performance 7.00% · Measure score 2.80 · Achievement 2.80 · Improvement 2.52
Total nurse turnover
5.51
Baseline 50.00% · Performance 41.18% · Measure score 5.51 · Achievement 5.51 · Improvement 3.01
Adjusted total nurse staffing
2.27
Baseline 3.84 hours · Performance 3.72 hours · Measure score 2.27 · Achievement 2.27 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.02% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 48 · Observed rate 10.42% · Lower 95% interval 7.23% |
| Discharge to community | 50.73% |
50.57%
0.2 pts better
|
No Different than the National Rate · Eligible stays 30 · Observed rate 46.67% · Lower 95% interval 37.96% |
| Medicare spending per beneficiary | 1.08 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 93.75% |
95.27%
1.5 pts worse
|
Numerator 45 · Denominator 48 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 48 |
| Discharge self-care score | 58.62% |
53.69%
4.9 pts better
|
Numerator 17 · Denominator 29 |
| Discharge mobility score | 48.28% |
50.94%
2.7 pts worse
|
Numerator 14 · Denominator 29 |
| Pressure ulcers or injuries, new or worsened | 10.42% |
2.29%
8.1 pts worse
|
Numerator 5 · Denominator 48 · Adjusted rate 8.66% |
| Healthcare-associated infections requiring hospitalization | 7% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 31 · Observed rate 6.45% · Lower 95% interval 4.22% |
| Staff COVID-19 vaccination coverage | 3.13% |
8.2%
5.1 pts worse
|
Numerator 2 · Denominator 64 |
| Staff flu vaccination coverage | 27.69% |
42%
14.3 pts worse
|
Numerator 18 · Denominator 65 |
| Discharge function score | 51.72% |
56.45%
4.7 pts worse
|
Numerator 15 · Denominator 29 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 24% |
25.2%
1.2 pts worse
|
Numerator 6 · Denominator 25 |
Quality measures
Resident outcomes and process scores
| 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 · Adjusted 1.8 · Observed 1.7 · Expected 1.9 · Used in QM five-star |
| 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 · Adjusted 3.0 · Observed 2.8 · Expected 1.5 · Used in QM five-star |
| 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 · Q1 98.1% · Q2 95.1% · Q3 100.0% · Q4 100.0% · 4Q avg 98.2% |
| 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 · 4Q avg 100.0% |
| 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 · Q1 5.7% · Q2 4.9% · Q3 3.4% · Q4 3.6% · 4Q avg 4.4% · Used in QM five-star |
| 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 · Q1 1.9% · Q2 18.9% · Q3 14.3% · Q4 5.6% · 4Q avg 10.2% |
| 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 · Q1 6.4% · Q2 3.4% · Q3 5.8% · Q4 10.0% · 4Q avg 6.3% |
| 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 · Q1 32.7% · Q2 25.9% · Q3 24.5% · Q4 27.5% · 4Q avg 27.5% |
| 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 · Q1 12.5% · Q2 13.7% · Q3 21.7% · Q4 15.9% · 4Q avg 16.0% · 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 · 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 | 10.5% |
21.5%
11 pts better
|
16.3%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 13.6% · Q3 9.2% · Q4 7.1% · 4Q avg 10.5% · Used in QM five-star |
| 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 · Q1 14.6% · Q2 12.5% · Q3 13.5% · Q4 2.2% · 4Q avg 10.9% · Used in QM five-star |
| 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 · Q1 3.9% · Q2 1.4% · Q3 0.0% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 5.4% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| 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 · Q1 17.5% · Q2 9.3% · Q3 17.2% · Q4 17.0% · 4Q avg 15.1% |
| 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 · Q1 8.9% · Q2 10.3% · Q3 2.1% · Q4 2.1% · 4Q avg 5.9% · Used in QM five-star |
| 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 · Q1 97.7% · Q2 95.1% · Q3 90.7% · Q4 97.6% · 4Q avg 95.3% |
| 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 · Adjusted 14.4% · Observed 13.5% · Expected 10.5% · Used in QM five-star |
| 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 · Q2 0.0% · Q3 0.0% · 4Q avg 1.2% · Used in QM five-star |
| 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 · 4Q avg 83.7% |
| 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 · Adjusted 14.3% · Observed 13.5% · Expected 22.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-02 · Fire 2023-11-02
14 health deficiencies
Top issue: Resident Rights (5 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2022-04-21 · Fire 2022-04-21
1 health 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 citations
D · Potential for more than minimal harm
2025-03-14
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 2025-05-09
D · Potential for more than minimal harm
2025-03-14
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2025-05-09
D · Potential for more than minimal harm
2025-03-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-09
D · Potential for more than minimal harm
2023-11-02
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-05-15
D · Potential for more than minimal harm
2023-11-02
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-05-15
D · Potential for more than minimal harm
2023-11-02
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 2024-05-15
D · Potential for more than minimal harm
2023-11-02
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-05-15
D · Potential for more than minimal harm
2023-11-02
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-05-15
D · Potential for more than minimal harm
2023-11-02
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-05-15
D · Potential for more than minimal harm
2023-11-02
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-05-15
D · Potential for more than minimal harm
2023-11-02
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-05-15
D · Potential for more than minimal harm
2023-11-02
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 2024-05-15
D · Potential for more than minimal harm
2023-11-02
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 2024-05-15
D · Potential for more than minimal harm
2023-11-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-05-15
D · Potential for more than minimal harm
2023-11-02
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-05-15
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-03-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-10
E · Potential for more than minimal harm
2025-03-14
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 2025-04-10
E · Potential for more than minimal harm
2025-03-14
F758 · Pharmacy Service Deficiencies
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
E · Potential for more than minimal harm
2025-03-14
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2025-04-10
D · Potential for more than minimal harm
2025-03-14
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 2025-04-10
D · Potential for more than minimal harm
2025-03-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-10
G · Actual harm
2023-11-02
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-11-27
G · Actual harm
2023-11-02
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 2023-11-27
F · Potential for more than minimal harm
2023-11-02
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 2023-11-27
F · Potential for more than minimal harm
2023-11-02
F882 · Infection Control Deficiencies
Health
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home.
Corrected 2023-11-27
E · Potential for more than minimal harm
2023-11-02
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-11-27
E · Potential for more than minimal harm
2023-11-02
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-11-27
E · Potential for more than minimal harm
2023-11-02
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 2023-11-27
E · Potential for more than minimal harm
2023-11-02
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-11-27
D · Potential for more than minimal harm
2023-11-02
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-11-27
D · Potential for more than minimal harm
2023-11-02
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 2023-11-27
D · Potential for more than minimal harm
2023-11-02
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 2023-11-27
D · Potential for more than minimal harm
2023-11-02
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 2023-11-27
D · Potential for more than minimal harm
2023-11-02
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-27
D · Potential for more than minimal harm
2023-11-02
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-11-27
D · Potential for more than minimal harm
2022-04-21
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 2022-04-25
Penalties and ownership
What sits behind the stars
$3,465
2023-11-02
Fine
Fine · fine $3,465
Fine
$6,305
2023-11-02
Fine
Fine · fine $6,305
Fine
Ownership
Fc Encore Andrews, LLC
5% Or Greater Security Interest · Organization
Hedden, Audrey
Operational/Managerial Control · Individual
Hoback, Tiffany
Operational/Managerial Control · Individual
Jones, Tequilla
Operational/Managerial Control · Individual
Moody, Amy
Operational/Managerial Control · Individual
Semones, Brandi
Operational/Managerial Control · Individual
Snf Mgr LLC
Operational/Managerial Control · Organization
Stover, Lani
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Graham Healthcare and Rehabilitation Center
Robbinsville, NC
3-star overall rating with 3-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Clay County Health and Rehabilitation
Hayesville, NC
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Chatuge Regional Nursing Home
Hiawassee, GA
1-star overall rating with 1-star inspections with $64,214 in total fines with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
Jump out