Cycle 1
Health 2025-08-07 · Fire 2024-05-07
5 health deficiencies
Top issue: Infection Control (1 deficiency)
6 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Charlotte, NC
Accordius Health at Midwood, LLC
2-star overall rating with 1-star inspections with $144,199 in total fines with 5 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
2727 Shamrock Drive, Charlotte, NC
(704) 519-2400
Overall
2 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
65
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Simcha Hyman & Naftali Zanziper
Operator or chain grouping
Approved since
1989-06-09
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
94 facilities
Chain averages 2 overall / 3 health / 2 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.66
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.88
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
1.70
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.25
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.55
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.02
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.62
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.79
CMS adjusted RN staffing hours
Adjusted total hours
3.84
CMS adjusted total nurse staffing hours
Case-mix index
1.16
Higher values indicate more complex resident acuity
RN turnover
70%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
87%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,464
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
16.69
Composite VBP score used to determine payment impact.
Payment multiplier
0.9817
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
0
Baseline 78.26% · Performance 88.75% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
3.34
Baseline 3.54 hours · Performance 4.03 hours · Measure score 3.34 · Achievement 3.34 · Improvement 1.68
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 18 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | 86.36% |
95.27%
8.9 pts worse
|
Numerator 19 · Denominator 22 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 22 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 4.55% |
2.29%
2.3 pts worse
|
Numerator 1 · Denominator 22 · Adjusted rate 3.77% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 13 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 59 |
| Staff flu vaccination coverage | 10.2% |
42%
31.8 pts worse
|
Numerator 15 · Denominator 147 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 85.0% |
91.5%
6.5 pts worse
|
93.4%
8.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 96.7% · Q2 91.4% · Q3 76.9% · Q4 76.2% · 4Q avg 85.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.4% |
94.1%
1.3 pts better
|
95.5%
0.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.6% |
3.6%
2 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.7% · Q3 1.5% · Q4 1.6% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.7% |
4.8%
2.1 pts better
|
11.4%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 11.1% · Q3 0.0% · Q4 0.0% · 4Q avg 2.7% |
| Percentage of long-stay residents who lose too much weight | 8.2% |
7.2%
1 pts worse
|
5.4%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.8% · Q2 8.6% · Q3 7.7% · Q4 9.5% · 4Q avg 8.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.9% |
21.6%
7.7 pts better
|
19.6%
5.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.9% · Q2 15.5% · Q3 12.3% · Q4 11.1% · 4Q avg 13.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.3% |
15.0%
4.3 pts worse
|
16.7%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.4% · Q2 22.2% · Q3 16.7% · Q4 14.9% · 4Q avg 19.3% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 13.4% |
21.5%
8.1 pts better
|
16.3%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 11.1% · Q3 14.6% · Q4 9.1% · 4Q avg 13.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.1% |
16.8%
7.7 pts better
|
14.9%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 5.8% · Q3 5.2% · Q4 7.3% · 4Q avg 9.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.9%
0.3 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 1.2% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
2.6%
2.6 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.6% |
21.2%
0.4 pts worse
|
19.8%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.5% · Q2 20.0% · Q3 25.0% · Q4 24.5% · 4Q avg 21.6% |
| Percentage of long-stay residents with pressure ulcers | 3.0% |
6.0%
3 pts better
|
5.1%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 2.1% · Q3 3.3% · Q4 4.8% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 28.4% |
79.9%
51.5 pts worse
|
81.7%
53.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 37.3% · Q2 40.3% · Q3 18.6% · Q4 5.9% · 4Q avg 28.4% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.5%
0.4 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.5% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 38.7% |
78.1%
39.4 pts worse
|
79.7%
41 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 38.7% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-07 · Fire 2022-12-30
15 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
5 fire-safety deficiencies
Top issue: Construction (2 deficiencies)
Cycle 3
Health 2022-12-30 · Fire 2021-12-16
8 health deficiencies
Top issue: Resident Rights (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-05-07
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-05-07
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-05-07
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-05-07
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-05-07
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-06-21
D · Potential for more than minimal harm
2024-05-07
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-06-21
D · Potential for more than minimal harm
2022-12-30
K111 · Construction Deficiencies
Fire Safety
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Corrected 2023-05-01
D · Potential for more than minimal harm
2022-12-30
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-05-01
D · Potential for more than minimal harm
2022-12-30
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-05-01
D · Potential for more than minimal harm
2022-12-30
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-05-01
D · Potential for more than minimal harm
2022-12-30
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-05-01
D · Potential for more than minimal harm
2021-12-16
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-01-25
D · Potential for more than minimal harm
2021-12-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-01-25
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-07
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2025-08-18
D · Potential for more than minimal harm
2025-08-07
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-08-18
D · Potential for more than minimal harm
2025-08-07
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-08-18
D · Potential for more than minimal harm
2025-08-07
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2025-08-18
D · Potential for more than minimal harm
2025-08-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-18
K · Immediate jeopardy
2024-05-07
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-05-24
K · Immediate jeopardy
2024-05-07
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-05-24
K · Immediate jeopardy
2024-05-07
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-05-24
K · Immediate jeopardy
2024-05-07
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-05-24
J · Immediate jeopardy
2024-05-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-05-24
E · Potential for more than minimal harm
2024-05-07
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2024-05-24
E · Potential for more than minimal harm
2024-05-07
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-05-24
E · Potential for more than minimal harm
2024-05-07
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-05-24
E · Potential for more than minimal harm
2024-05-07
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2024-05-24
E · Potential for more than minimal harm
2024-05-07
F809 · Nutrition and Dietary Deficiencies
Health
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.
Corrected 2024-05-24
E · Potential for more than minimal harm
2024-05-07
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-05-24
D · Potential for more than minimal harm
2024-05-07
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-05-24
D · Potential for more than minimal harm
2024-05-07
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-05-24
D · Potential for more than minimal harm
2024-05-07
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-05-24
D · Potential for more than minimal harm
2024-05-07
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-05-24
G · Actual harm
2022-12-30
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-02-10
G · Actual harm
2022-12-30
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-02-10
E · Potential for more than minimal harm
2022-12-30
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-02-10
E · Potential for more than minimal harm
2022-12-30
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-02-10
D · Potential for more than minimal harm
2022-12-30
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-02-10
D · Potential for more than minimal harm
2022-12-30
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2023-02-10
D · Potential for more than minimal harm
2022-12-30
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-02-10
D · Potential for more than minimal harm
2022-12-30
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2023-02-10
Penalties and ownership
What sits behind the stars
$144,199
2024-05-07
Fine
Fine · fine $144,199
Fine
Ownership
Nearby options
Other facilities in reach
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2-star overall rating with 2-star inspections with $53,176 in total fines with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Peak Resources - Charlotte
Charlotte, NC
3-star overall rating with 3-star inspections with $14,069 in total fines with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Wilora Lake Healthcare
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3-star overall rating with 3-star inspections with 10 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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