Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pisgah Manor Health Care Center during CMS and state inspections, most recent first.
Failure to use EBP during catheter care: An RN performed catheter care for a resident with an indwelling urinary catheter without wearing a gown, despite an EBP sign posted outside the room and gowns available on a PPE cart inside. The RN used gloves and hand hygiene but initially stated she thought EBP applied only to wound care, while the DON confirmed gowns should have been worn for catheter care and other indwelling devices.
During a COVID-19 outbreak, the facility did not implement broad-based testing for staff and residents when contact tracing failed to stop transmission, resulting in delayed identification of positive cases across multiple units. Staff testing was inconsistent, with many only tested if symptomatic, and there was no comprehensive tracking of test results. The facility also failed to implement source control measures such as universal masking and did not restrict staff from returning to work after testing positive, contrary to CDC guidance. Communication with the local Health Department was delayed, and the facility's policies were not updated to reflect current CDC recommendations.
Surveyors found that leftover breaded fish filets in the walk-in freezer were stored in an open, undated bag, with a thin white layer observed on the edges. Staff interviews confirmed that opened foods should be dated and sealed, but this was not done for the fish filets.
Failure to Use EBP During Catheter Care
Penalty
Summary
The facility failed to follow its infection control policy for Enhanced Barrier Precautions (EBP) when Nurse #1 did not wear a gown while providing catheter care to Resident #3. The facility policy, last approved 6/2025, stated that EBP include the use of gown and gloves during high-contact resident care activities for residents with wounds or indwelling medical devices, including urinary catheters. During observation on 5/20/26, an EBP sign was posted outside Resident #3’s room and a PPE cart with gowns was inside the room, but Nurse #1 performed hand hygiene, donned gloves, and completed catheter care without putting on a gown. The nurse cleaned around the urinary meatus and along the length of the indwelling urinary catheter several times, removed her gloves, performed hand hygiene, then put on new gloves to adjust the catheter securement device on the resident’s thigh, again without wearing a gown. In interview, Nurse #1 initially stated she believed EBP were only for wound care and not for catheter care or indwelling devices, then acknowledged after reviewing the sign that EBP were required for indwelling devices. The DON confirmed that EBP should be used for residents with catheters and indwelling devices and that Nurse #1 should have worn a gown during the catheter care.
Failure to Implement COVID-19 Infection Control Measures During Outbreak
Penalty
Summary
The facility failed to operationalize its infection prevention and control program in accordance with current CDC guidance during a COVID outbreak. Despite having a policy that outlined procedures for testing and outbreak response, the facility did not implement broad-based COVID testing for staff and residents when contact tracing failed to halt transmission. Instead, testing was limited to symptomatic individuals or those who requested it, and there was no comprehensive system for tracking or logging staff test results. This resulted in delayed identification of positive cases, with broad-based testing not initiated until several staff and residents had already tested positive across multiple halls. Staff interviews revealed inconsistent testing practices, with many staff members reporting they were only tested if symptomatic or after known exposure outside the facility. Several staff who worked on affected units were not tested or did not have repeat testing, and therapy staff were largely absent from testing logs. The facility also failed to implement source control measures, such as universal masking, during the outbreak, and did not restrict staff from returning to work after testing positive for COVID in accordance with CDC guidance. Additionally, the facility's COVID policies and procedures were not updated to align with current CDC recommendations for source control and work restrictions for healthcare personnel. Communication with the local Health Department was inadequate, as the facility did not promptly notify the department of the outbreak or seek guidance. The Health Department Nurse confirmed that she had not received timely notification and would have recommended immediate broad-based testing and source control measures had she been informed. The lack of a coordinated response, incomplete testing, and failure to follow established protocols contributed to ongoing transmission of COVID among residents and staff, with multiple residents requiring hospitalization due to COVID-related symptoms.
Failure to Date and Seal Leftover Frozen Food in Kitchen
Penalty
Summary
Surveyors observed that the facility failed to date and seal leftover frozen food stored in the walk-in freezer. Specifically, a clear plastic bag containing breaded fish filets was found open to air, not sealed, and without a date. The edges of the fish filets had a thin white layer around them. Both the Dietary Director and the Registered Dietitian confirmed during interviews that all opened foods should be dated and sealed. The Administrator also stated that opened food should be dated when returned to the refrigerator or freezer, but was unsure if sealing was required. The deficiency was identified during an initial kitchen observation and confirmed through staff interviews.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Candler
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aston Park Health Care Center | 4.5 mi | ★★★★★ | 2 | 0 |
| River Bend Health And Rehabilitation | 5.9 mi | ★★★★★ | 4 | 0 |
| Stonecreek Health And Rehabilitation | 6.6 mi | ★★★★★ | 0 | 0 |
| Elevate Health And Rehabilitation | 6.9 mi | ★★★★★ | 4 | 1 |
| Emerald Ridge Health And Rehabilitation | 7.5 mi | ★★★★★ | 11 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.