Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

Valley Hill Health & Rehab Center

Hendersonville, NC · 150 certified beds · Last Life Safety survey April 10, 2024

CMS Certification Number 345223 · first certified June 1982

Ownership

Operated by SABER HEALTHCARE GROUP · For profit - Corporation

Ownership changed November 1, 2022 (change of ownership)to VALLEY HILL HEALTH & REHAB CENTER, LLC from HEBRON OPERATING COMPANY LLC

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within NC

30 citations — more than 98% of the 419 certified nursing homes in NC. Compared within NC rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Holding steadyabout the same at the latest survey as at its earlier surveys in the window.

The latest survey found 10 citations; the earlier surveys in the window averaged 10. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

Well past the typical window (June 2025 to August 2025), and past the point by which nine in ten NC facilities have been surveyed. This facility’s last Life Safety survey was April 2024. Facilities in NC are typically surveyed 14–16 months after the last one (median 15), measured over 412 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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3 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Physical environment (health survey)

4 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 30 Life Safety citations above. The Physical Environment Index

F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F-0880 Provide and implement an infection prevention and control program.

How that compares

Citations on file over three years

Compared with the median facility in NC, and nationally. Surveyors differ markedly between states, so the NC figure is the meaningful one.

Citations on file over three years, compared
Measure	Citations
This facility	30
Median facility in NC	9
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
July 1, 2021	2
January 20, 2023	18
April 10, 2024	10

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
K-0222	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.	3	2024-04-10
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	3	2024-04-10
K-0353	Inspect, test, and maintain automatic sprinkler systems.	2	2024-04-10
K-0372	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	2	2024-04-10
K-0914	Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.	2	2024-04-10
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	2	2024-04-10
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	1	2024-04-10
K-0161	Use approved construction type or materials.	1	2023-01-20

What the citations cover

Citations by CMS category

Smoke Deficiencies 11
Egress Deficiencies 8
Gas, Vacuum, and Electrical Systems Deficiencies 6
Services Deficiencies 2
Other 3

Citations by CMS category
Category	Citations
Smoke Deficiencies	11
Egress Deficiencies	8
Gas, Vacuum, and Electrical Systems Deficiencies	6
Services Deficiencies	2
Miscellaneous Deficiencies	2
Construction Deficiencies	1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

April 10, 2024 — 10 citations

Citations issued on April 10, 2024
Tag	What the surveyor checks	Status
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	Deficient, Provider has date of correction (July 31, 2024)
K-0222	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.	Deficient, Provider has date of correction (July 31, 2024)
K-0281	Install proper backup exit lighting.	Deficient, Provider has date of correction (July 31, 2024)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (July 31, 2024)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (July 31, 2024)
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	Deficient, Provider has date of correction (July 31, 2024)
K-0372	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	Deficient, Provider has date of correction (July 31, 2024)
K-0761	To conduct inspection, testing and maintenance of fire doors by qualified individuals.	Deficient, Provider has date of correction (July 31, 2024)
K-0914	Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.	Deficient, Provider has date of correction (July 31, 2024)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (July 31, 2024)

January 20, 2023 — 18 citations

Citations issued on January 20, 2023
Tag	What the surveyor checks	Status
K-0161	Use approved construction type or materials.	Deficient, Provider has date of correction (May 18, 2023)
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	Deficient, Provider has date of correction (May 18, 2023)
K-0222	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.	Deficient, Provider has date of correction (May 18, 2023)
K-0293	Have properly located and lighted "Exit" signs.	Deficient, Provider has date of correction (May 18, 2023)
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (May 18, 2023)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (May 18, 2023)
K-0341	Install a fire alarm system that can be heard throughout the facility.	Deficient, Provider has date of correction (May 18, 2023)
K-0351	Install an approved automatic sprinkler system.	Deficient, Provider has date of correction (May 18, 2023)
K-0352	Properly install and monitor supervisory attachments on automatic sprinkler systems.	Deficient, Provider has date of correction (May 18, 2023)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (May 18, 2023)
K-0372	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	Deficient, Provider has date of correction (May 18, 2023)
K-0511	Have properly installed electrical wiring and gas equipment.	Deficient, Provider has date of correction (May 18, 2023)
K-0521	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Deficient, Provider has date of correction (May 18, 2023)
K-0741	Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.	Deficient, Provider has date of correction (May 18, 2023)
K-0914	Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.	Deficient, Provider has date of correction (May 18, 2023)
K-0916	Have a battery powered remote alarm panel in a location accessible by operating personnel.	Deficient, Provider has date of correction (May 18, 2023)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (May 18, 2023)
K-0923	Have proper medical gas storage and administration areas.	Deficient, Provider has date of correction (May 18, 2023)

July 1, 2021 — 2 citations

Citations issued on July 1, 2021
Tag	What the surveyor checks	Status
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	Deficient, Provider has date of correction (August 6, 2021)
K-0222	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.	Deficient, Provider has date of correction (August 6, 2021)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.