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Pisgah Manor Health Care Center

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

104 Holcombe Cove Road, Candler, NC 28715118 bedsLicensed & Active
1/5
Medicare
Inspection
Quality
Staffing
Google rating
4.0/5

based on 56 Google reviews

5
4
3
2
1
Pisgah Manor Health Care Center Nursing Home in Candler, NC — Street View
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3/ 10
moderate Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Low overall rating (1/5 stars)
  • Low staffing rating (2/5 stars)

Bottom 25% in NC · Below recommended RN staffing · Significantly below average staffing · Worst in LIBERTY SENIOR LIVING chain · $58,516 in fines · Very few deficiencies

Source: Medicare data

What this means for your family

Pisgah Manor is frequently praised for its effective rehabilitation program and clean facility, making it a strong candidate for short-term recovery. However, families should be aware of consistent reports regarding staffing shortages and slow response times. We strongly recommend visiting during a weekend or holiday to observe staffing levels firsthand before making a decision.

Google Reviews

Google Reviews

56 reviews on Google
Pisgah Manor Health Care Center receives highly polarized feedback, with many families praising the facility for its clean environment and effective rehabilitation services. However, a recurring pattern of critical reviews highlights significant concerns regarding chronic understaffing, slow response times to call buttons, and poor administrative communication. Families considering this facility should be aware of these inconsistencies in care quality, particularly during weekends and holidays.

Quality Themes

Tap a score for details
Food8.0Staff6.0Clean8.0Activities7.0Meds7.0Memory4.0Comms3.0ValueN/A

Strengths

  • Effective and professional rehabilitation therapy team
  • Clean, well-maintained, and bright facility
  • Compassionate and attentive nursing staff (noted by many)
  • Good quality food and dining options

Concerns

  • Slow response times to call buttons (mentioned by 2 reviewers)
  • Chronic understaffing, especially on weekends/holidays (mentioned by 4 reviewers)
  • Poor administrative communication and billing issues (mentioned by 3 reviewers)

Rating Trends

Tap a year to see what changed

234'16(2)'18(2)'20(2)'22(12)'24(7)'26(12)

Distribution · 60 analyzed

5
44
4
1
3
0
2
1
1
14

How They Respond to Reviews

97%response rate

This facility actively engages with reviewer feedback.

Questions for Your Tour

  • 1It's wonderful to see how bright and well-maintained the facility is; what specific cleaning protocols do you have in place to keep the common areas so tidy?
  • 2We've heard great things about the rehabilitation therapy team here; could you tell us more about how they work with residents to meet their mobility goals?
  • 3How do you ensure that call buttons are answered promptly, especially during the busier weekend or holiday shifts?
  • 4What is your process for keeping families updated on changes in a resident's care or any administrative updates?
  • 5Could you describe the dining experience and how much variety there is in the daily meal options?
  • 6How does the nursing team handle medical emergencies or urgent care needs during the overnight hours?

Personalized based on this facility's data


Key Review Excerpts

My mother who has stage 4 cancer went to Pisgah Manor for rehabilitation. They worked with her daily and helped her reach her goal to walk an come back home. The staff in all areas were amazing.

Rehab patient's family · 2024★★★★★

My dad was here for two weeks and he was treated amazing! All the nurses, physical therapists, occupational therapists, CNAs... were wonderful! It is hard enough having to admit a loved one... but Pisgah Manor made this easy.

Rehab patient's family · 2022★★★★★

The facility was short staffed on a holiday weekend and the on duty RN on her first day in the facility. The financial documentation was 1-2 months in arrear.

Long-term resident's family · 2025☆☆☆☆
Source: 56 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.62hrs
82%
Registered nurses for medical care
Total Nursing
2.90hrs
71%
All nurses + aides combined
Staff Turnover
52%
Lower is better (< 30% = good)
RN Turnover
50%
Lower is better (< 30% = good)

Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 17 measures

Medicare Rating
2/ 5
Better Than Avg

8

measures

Worse Than Avg

7

measures

Mixed Results

2

measures

Long-Stay Residents
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility27.0%
Worse than Avg
Here
27.0%
US
19.4%
NC
21.0%
Buncombe
24.7%
😔

Residents with depression symptoms

↓ Lower is better
This Facility4.5%
Mixed vs Avgs
Here
4.5%
US
12.1%
NC
5.4%
Buncombe
2.4%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

💉

Residents vaccinated for pneumonia

↑ Higher is better
This Facility97.9%
Better than Avg
Here
97.9%
US
93.4%
NC
91.7%
Buncombe
91.0%
⚠️

Residents who fell and were seriously hurt

↓ Lower is better
This Facility10.0%
Worse than Avg
Here
10.0%
US
3.2%
NC
3.5%
Buncombe
5.7%
💉

Residents vaccinated for the flu

↑ Higher is better
This Facility98.9%
Better than Avg
Here
98.9%
US
95.5%
NC
94.1%
Buncombe
93.3%
🚶

Residents whose walking got worse

↓ Lower is better
This Facility15.1%
Better than Avg
Here
15.1%
US
15.3%
NC
20.2%
Buncombe
19.5%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility87.9%
Better than Avg
Here
87.9%
US
81.8%
NC
80.1%
Buncombe
79.1%
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility81.6%
Better than Avg
Here
81.6%
US
79.8%
NC
78.1%
Buncombe
77.3%
💊

Short-stay residents newly given antipsychotics

↓ Lower is better
This Facility2.4%
Worse than Avg
Here
2.4%
US
1.6%
NC
1.5%
Buncombe
1.9%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

2deficiencies
1penalties
Well below state avg (5.6)
4 complaint-triggered
$58,516 in fines

Families reported concerns that triggered federal complaints about resident rights, daily care assistance, wound care, and nursing staffing levels. Pisgah Manor has recurring deficiencies in resident rights, infection control, and food safety that span multiple surveys, though all violations have been corrected by the facility. The most recent 2025 survey showed fewer issues compared to earlier inspections, suggesting some improvement in care quality.

Apr 1, 2025Routine
5
0880Immediate jeopardy · WidespreadCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0911Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Meet requirements for the installation and maintenance of electrical systems.

0812Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0321Potential for harm · IsolatedCorrected

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

0324Potential for harm · IsolatedCorrected

Smoke Deficiencies

Provide properly protected cooking facilities.

Dec 6, 2023Routine
7
0761Potential for harm · PatternCorrected

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.

0812Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0867Potential for harm · PatternCorrected

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

0641Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

0644Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

0345Potential for harm · IsolatedCorrected

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

0918Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Dec 6, 2023Complaint
4
0550Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

0677Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

0686Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

0725Potential for harm · IsolatedCorrected

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Jun 10, 2022Routine
22
0550Actual harm · PatternCorrected

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

0725Actual harm · PatternCorrected

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

0880Potential for harm · WidespreadCorrected

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

0561Potential for harm · PatternCorrected

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

0677Potential for harm · PatternCorrected

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

0812Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0554Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

0558Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

0578Potential for harm · IsolatedCorrected

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.

0583Potential for harm · IsolatedCorrected

Resident Rights Deficiencies

Keep residents' personal and medical records private and confidential.

0622Potential for harm · IsolatedCorrected

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.

0641Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

0644Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

0657Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

0686Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

0695Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

0810Potential for harm · IsolatedCorrected

Nutrition and Dietary Deficiencies

Provide special eating equipment and utensils for residents who need them and appropriate assistance.

0842Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

0363Potential for harm · IsolatedCorrected

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

0911Potential for harm · IsolatedCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Meet requirements for the installation and maintenance of electrical systems.

0888Minimal · WidespreadCorrected

Infection Control Deficiencies

Ensure staff are vaccinated for COVID-19

Federal Penalties

Fine

Apr 1, 2025

$59,391

Ownership & Operations

Who Operates This Facility

Owner / Operator

Pisgah Manor Health Care Center

Organization Type

for profit

Chain Affiliation

Chain Name

Liberty Senior Living

Chain Size

37 facilities nationwide

Chain avg rating: 2.6/5 · Rank 32 of 35 (Worst)

Ownership & Management

Owners

Long Term Care Management Services LLC

Owner · Organization

100%

Key personnel

Miller, RobertOfficer / DirectorPurifoy, PennyOfficer / DirectorCalcutt, JosephOfficer / DirectorWilson, JeffreyOfficer / DirectorLong Term Care Management Services LLCManager
Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 6 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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