Buncombe County — Asheville and the western mountains — runs 19 facilities and 79 surveys at 5.28 deficiencies each. Its 13.9% Immediate-Jeopardy rate sits below Charlotte and Raleigh but well above the national norm. Buncombe's signature isn't the sharp clinical end — it's kitchen sanitation, infection control, and a quality-assurance process that surveyors find missing.
The local fingerprint
Kitchen, infection, and a hollow QAPI
Buncombe over-indexes hard on the environmental tags: kitchen sanitation (F812) at 1.86× the state rate, with storage sanitation in 92% of those citations, and infection control (F880) at 1.56×. Its QAPI citations (F867) are especially blunt — every one involves no improvement projects and no systematic analysis. The PASARR and assessment-coordination tag (F644) also spikes at 2.84×. This is a county where the management systems behind care, not just the care itself, draw the surveyor's attention.
Run the environmental basics relentlessly: kitchen storage sanitation (F812) and infection-control policy (F880) drive the county's volume. Then stand up a real QAPI program (F867) — documented improvement projects and systematic analysis, not a binder — and tighten PASARR and assessment coordination (F644). Buncombe's risk is systemic, so the fix is a working quality system.