Pisgah Manor Health Care Center
104 Holcombe Cove Road · Candler, NC · 28715 · 8286679851
118 certified beds For profit - Corporation Chain: Liberty Senior Living Part of a CCRC
Why this verdict
- Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (1 citation).
- Inspection record is far worse than the national median (deficiency count and severity).
- Inspection results are getting worse cycle over cycle, not better.
Red flags
1 immediate-jeopardy citation in the most recent inspection cycle
Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.
$59,391 in federal fines in the last 24 months
1 fine — CMS fines are reserved for verified, serious non-compliance.
Total nurse staffing below 3.0 hours per resident-day
2.90 reported hours vs the 3.48 minimum CMS's own staffing study recommends.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 2 of 5 Quality measures: 2 of 5
| Total nurse hours / resident-day | 2.90 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.62 | 0.55–0.75 |
| Weekend hours / resident-day | 2.68 | ≈ weekday level |
| Nursing turnover / year | 52% | median 45% |
| Fines (3-yr window) | 1 · $59,391 |
Inspection citations (31 in the current record)
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Immediate jeopardy · L April 1, 2025
Provide and implement an infection prevention and control program.
Corrected April 2, 2025 · Infection Control
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Potential for harm · E April 1, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected April 2, 2025 · Nutrition and Dietary
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Potential for harm · D December 6, 2023
Ensure each resident receives an accurate assessment.
Corrected January 2, 2024 · Resident Assessment and Care Planning
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Potential for harm · D December 6, 2023
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected January 2, 2024 · Resident Assessment and Care Planning
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Potential for harm · E December 6, 2023
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.
Corrected January 2, 2024 · Pharmacy Service
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Potential for harm · E December 6, 2023
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected January 2, 2024 · Nutrition and Dietary
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Potential for harm · E December 6, 2023
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected January 2, 2024 · Administration
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Potential for harm · D December 6, 2023 · found via complaint
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected January 2, 2024 · Resident Rights
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Potential for harm · D December 6, 2023 · found via complaint
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected January 2, 2024 · Quality of Life and Care
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Potential for harm · D December 6, 2023 · found via complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected January 2, 2024 · Quality of Life and Care
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Potential for harm · D December 6, 2023 · found via complaint
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected January 2, 2024 · Nursing and Physician Services
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Actual harm · H June 10, 2022
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected July 4, 2022 · Resident Rights
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Actual harm · H June 10, 2022
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected July 4, 2022 · Nursing and Physician Services
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Potential for harm · D June 10, 2022
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected July 4, 2022 · Resident Rights
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Potential for harm · D June 10, 2022
Reasonably accommodate the needs and preferences of each resident.
Corrected July 4, 2022 · Resident Rights
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Potential for harm · E June 10, 2022
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected July 4, 2022 · Resident Rights
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Potential for harm · D June 10, 2022
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.
Corrected July 4, 2022 · Resident Rights
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Potential for harm · D June 10, 2022
Keep residents' personal and medical records private and confidential.
Corrected July 4, 2022 · Resident Rights
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Potential for harm · D June 10, 2022
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.
Corrected July 4, 2022 · Resident Rights
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Potential for harm · D June 10, 2022
Ensure each resident receives an accurate assessment.
Corrected July 4, 2022 · Resident Assessment and Care Planning
-
Potential for harm · D June 10, 2022
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected July 4, 2022 · Resident Assessment and Care Planning
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Potential for harm · D June 10, 2022
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected July 4, 2022 · Resident Assessment and Care Planning
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Potential for harm · E June 10, 2022
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected July 4, 2022 · Quality of Life and Care
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Potential for harm · D June 10, 2022
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected July 4, 2022 · Quality of Life and Care
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Potential for harm · D June 10, 2022
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected July 4, 2022 · Quality of Life and Care
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| April 1, 2025 | Fine | $59,391 |
Family & resident reviews — a separate signal, never mixed into the score
No approved reviews yet. If your family has experience with this facility, yours could be the review that helps the next family decide.
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 345393 · certified since July 16, 1991. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.