Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Elderberry Health Care
Marshall, NC · 80 certified beds · Last Life Safety survey August 28, 2024
CMS Certification Number 345319 · first certified May 1990
Ownership
Independently operated (no chain recorded by CMS) · For profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within NC
13 citations — more than 65% 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
The latest survey found 9 citations; the earlier surveys in the window averaged 2. 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 (October 2025 to December 2025), and past the point by which nine in ten NC facilities have been surveyed. This facility’s last Life Safety survey was August 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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2 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.
Emergency preparedness
1 of the 13 citations on file is Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
1 physical-environment citation 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 13 Life Safety citations above. The Physical Environment Index
- F-0584 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.
How that compares
Compared with the median facility in NC, and nationally. Surveyors differ markedly between states, so the NC figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 13 |
| Median facility in NC | 9 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| October 28, 2021 | 0 |
| June 22, 2023 | 4 |
| August 28, 2024 | 9 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 2 | 2024-08-28 |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 2 | 2024-08-28 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2024-08-28 |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | 1 | 2024-08-28 |
| 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. | 1 | 2024-08-28 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 1 | 2023-06-22 |
| E-0001 | Establish an Emergency Preparedness Program (EP). | 1 | 2024-08-28 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 1 | 2024-08-28 |
What the citations cover
- Smoke Deficiencies 6
- Services Deficiencies 3
- Gas, Vacuum, and Electrical Systems Deficiencies 2
- Egress Deficiencies 1
- Other 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 6 |
| Services Deficiencies | 3 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
| Egress Deficiencies | 1 |
| Emergency Preparedness Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
August 28, 2024 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0001 | Establish an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (October 25, 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 (December 19, 2024) |
| 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 (December 19, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (December 19, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (December 19, 2024) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (December 19, 2024) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (December 19, 2024) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (December 19, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (December 19, 2024) |
June 22, 2023 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| 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 (October 16, 2023) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (October 16, 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 (October 16, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (October 16, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.