Sapphire Ridge Health and Rehabilitation Inspection Report, Violations & Safety Grade (Brevard, North Carolina)

115 N Country Club Road, Brevard, North Carolina 28712

Phone: 8288842031

CMS Overall:2/5

Overview & Bed Count

Certified Beds

147

Avg Residents/Day

107.2

Ownership

For profit - Limited Liability company

Provider Type

Medicare and Medicaid

County

Transylvania

Sprinkler Systems

Yes

Special Focus

None

Abuse Icon

CMS Star Ratings

Overall2/5

Health2/5

Staffing3/5

Quality3/5

Nurse Staffing Check

Metric	This Facility	North Carolina Avg	Difference
RN Hours per Resident per Day	0.43	0.62	-0.19
Total Nurse Hours per Resident per Day	3.52	3.87	-0.35
CMS Staffing Rating	3/5	2.7/5	-
Nursing Staff Turnover	47.8%	48.7%	-

Health Citation History

29 health citations on record

Date	Category	Description	Severity
2026-05-07	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	E – Moderate Harm Potential
2026-05-07	Resident Assessment and Care Planning Deficiencies	PASARR screening for Mental disorders or Intellectual Disabilities	D – Moderate Harm Potential
2026-05-07	Quality of Life and Care Deficiencies	Provide care and assistance to perform activities of daily living for any resident who is unable.	D – Moderate Harm Potential
2026-05-07	Resident Rights Deficiencies	Ensure residents have reasonable access to and privacy in their use of communication methods.	C – Minimal Harm Potential
2025-03-07	Nutrition and Dietary Deficiencies	Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.	E – Moderate Harm Potential
2025-03-07	Nutrition and Dietary Deficiencies	Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.	E – Moderate Harm Potential
2025-03-07	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	E – Moderate Harm Potential
2025-03-07	Infection Control Deficiencies	Develop and implement policies and procedures for flu and pneumonia vaccinations.	E – Moderate Harm Potential
2025-03-07	Infection Control Deficiencies	Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.	E – Moderate Harm Potential
2025-03-07	Resident Rights Deficiencies	Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.	D – Moderate Harm Potential
2025-03-07	Resident Rights Deficiencies	Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.	D – Moderate Harm Potential
2025-03-07	Resident Rights Deficiencies	Honor the resident's right to organize and participate in resident/family groups in the facility.	D – Moderate Harm Potential
2025-03-07	Resident Rights Deficiencies	Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.	D – Moderate Harm Potential
2025-03-07	Freedom from Abuse, Neglect, and Exploitation Deficiencies	Respond appropriately to all alleged violations.	D – Moderate Harm Potential
2025-03-07	Resident Assessment and Care Planning Deficiencies	Ensure each resident receives an accurate assessment.	D – Moderate Harm Potential
2025-03-07	Quality of Life and Care Deficiencies	Provide care and assistance to perform activities of daily living for any resident who is unable.	D – Moderate Harm Potential
2023-11-17	Resident Rights Deficiencies	Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.	E – Moderate Harm Potential
2023-11-17	Resident Rights Deficiencies	Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.	E – Moderate Harm Potential
2023-11-17	Quality of Life and Care Deficiencies	Provide appropriate treatment and care according to orders, resident’s preferences and goals.	E – Moderate Harm Potential
2023-11-17	Pharmacy Service Deficiencies	Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.	E – Moderate Harm Potential
2023-11-17	Nutrition and Dietary Deficiencies	Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.	E – Moderate Harm Potential
2023-11-17	Nutrition and Dietary Deficiencies	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.	E – Moderate Harm Potential
2023-11-17	Administration Deficiencies	Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.	E – Moderate Harm Potential
2023-11-17	Resident Rights Deficiencies	Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.	D – Moderate Harm Potential
2023-11-17	Resident Assessment and Care Planning Deficiencies	Ensure each resident receives an accurate assessment.	D – Moderate Harm Potential
2023-11-17	Resident Assessment and Care Planning Deficiencies	Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.	D – Moderate Harm Potential
2023-11-17	Quality of Life and Care Deficiencies	Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.	D – Moderate Harm Potential
2023-11-17	Quality of Life and Care Deficiencies	Provide safe and appropriate respiratory care for a resident when needed.	D – Moderate Harm Potential
2023-11-17	Resident Rights Deficiencies	Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.	B – Minimal Harm Potential

Fire Safety Citation History

28 fire safety citations on record

Date	Category	Description	Severity
2026-05-07	Egress Deficiencies	Keep aisles, corridors, and exits free of obstruction in case of emergency.	F – Moderate Harm Potential
2026-05-07	Smoke Deficiencies	Provide properly protected cooking facilities.	E – Moderate Harm Potential
2026-05-07	Construction Deficiencies	Use approved construction type or materials.	D – Moderate Harm Potential
2026-05-07	Egress Deficiencies	Install proper backup exit lighting.	D – Moderate Harm Potential
2026-05-07	Smoke Deficiencies	Have an enclosure around a vertical opening shaft.	D – Moderate Harm Potential
2026-05-07	Smoke Deficiencies	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	D – Moderate Harm Potential
2026-05-07	Smoke Deficiencies	Have approved installation, maintenance and testing program for fire alarm systems.	D – Moderate Harm Potential
2026-05-07	Smoke Deficiencies	Install corridor and hallway doors that block smoke.	D – Moderate Harm Potential
2026-05-07	Services Deficiencies	Have properly installed electrical wiring and gas equipment.	D – Moderate Harm Potential
2026-05-07	Services Deficiencies	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	D – Moderate Harm Potential
2025-03-07	Construction Deficiencies	Use approved construction type or materials.	D – Moderate Harm Potential
2025-03-07	Smoke Deficiencies	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	D – Moderate Harm Potential
2025-03-07	Services Deficiencies	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	D – Moderate Harm Potential
2025-03-07	Miscellaneous Deficiencies	Have simulated fire drills held at unexpected times.	D – Moderate Harm Potential
2025-03-07	Gas, Vacuum, and Electrical Systems Deficiencies	Meet requirements for the installation and maintenance of electrical systems.	D – Moderate Harm Potential
2025-03-07	Gas, Vacuum, and Electrical Systems Deficiencies	Have generator or other power source capable of supplying service within 10 seconds.	D – Moderate Harm Potential
2023-11-17	Egress Deficiencies	Keep aisles, corridors, and exits free of obstruction in case of emergency.	F – Moderate Harm Potential
2023-11-17	Smoke Deficiencies	Have approved installation, maintenance and testing program for fire alarm systems.	F – Moderate Harm Potential
2023-11-17	Smoke Deficiencies	Install smoke barrier doors that can resist smoke for at least 20 minutes.	F – Moderate Harm Potential
2023-11-17	Services Deficiencies	Have properly installed electrical wiring and gas equipment.	F – Moderate Harm Potential
2023-11-17	Smoke Deficiencies	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	E – Moderate Harm Potential
2023-11-17	Egress Deficiencies	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.	D – Moderate Harm Potential
2023-11-17	Smoke Deficiencies	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	D – Moderate Harm Potential
2023-11-17	Smoke Deficiencies	Inspect, test, and maintain automatic sprinkler systems.	D – Moderate Harm Potential
2023-11-17	Smoke Deficiencies	Install corridor and hallway doors that block smoke.	D – Moderate Harm Potential
2023-11-17	Services Deficiencies	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	D – Moderate Harm Potential
2023-11-17	Gas, Vacuum, and Electrical Systems Deficiencies	Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.	D – Moderate Harm Potential
2023-11-17	Gas, Vacuum, and Electrical Systems Deficiencies	Have proper medical gas storage and administration areas.	D – Moderate Harm Potential

Total Penalties & Fines

$22,568

Total Fine Amount (CMS)

Number of Fines

Total Penalties

Date	Type	Fine Amount	Payment Denial
2023-11-17	Fine	$22,568	-

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