Cycle 1
Health 2025-04-10 · Fire 2025-04-10
4 health deficiencies
Top issue: Resident Rights (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Monroe, NC
Accordius Health at Monroe
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
204 Old Highway 74 East, Monroe, NC
(704) 800-0601
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
53
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Simcha Hyman & Naftali Zanziper
Operator or chain grouping
Approved since
1991-01-30
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
0.68
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.62
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
1.95
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.26
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.31
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.00
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.60
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.72
CMS adjusted RN staffing hours
Adjusted total hours
3.41
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
78%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
67%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,074
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.51
Composite VBP score used to determine payment impact.
Payment multiplier
0.9826
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
4.01
Baseline 7.30% · Performance 6.64% · Measure score 4.01 · Achievement 4.01 · Improvement 2.39
Total nurse turnover
0.05
Baseline 69.56% · Performance 67.12% · Measure score 0.05 · Achievement 0 · Improvement 0.05
Adjusted total nurse staffing
2.40
Baseline 3.34 hours · Performance 3.76 hours · Measure score 2.40 · Achievement 2.40 · Improvement 1.23
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.67% |
10.72%
2.1 pts better
|
No Different than the National Rate · Eligible stays 68 · Observed rate 2.94% · Lower 95% interval 5.32% |
| Discharge to community | 43.64% |
50.57%
6.9 pts worse
|
No Different than the National Rate · Eligible stays 54 · Observed rate 33.33% · Lower 95% interval 31.08% |
| Medicare spending per beneficiary | 0.83 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 32 · Denominator 32 |
| Falls with major injury | 3.13% |
0.77%
2.4 pts worse
|
Numerator 1 · Denominator 32 |
| Discharge self-care score | 72% |
53.69%
18.3 pts better
|
Numerator 18 · Denominator 25 |
| Discharge mobility score | 32% |
50.94%
18.9 pts worse
|
Numerator 8 · Denominator 25 |
| Pressure ulcers or injuries, new or worsened | 3.13% |
2.29%
0.8 pts worse
|
Numerator 1 · Denominator 32 · Adjusted rate 3.49% |
| Healthcare-associated infections requiring hospitalization | 6.64% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 28 · Observed rate 3.57% · Lower 95% interval 3.37% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 69 |
| Staff flu vaccination coverage | 7.14% |
42%
34.9 pts worse
|
Numerator 5 · Denominator 70 |
| Discharge function score | 48% |
56.45%
8.5 pts worse
|
Numerator 12 · Denominator 25 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 15 · 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 | 100.0% |
91.5%
8.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.1%
5.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.7% |
3.6%
1.1 pts worse
|
3.3%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.4% · Q2 4.3% · Q3 4.3% · Q4 4.1% · 4Q avg 4.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.8%
4.8 pts better
|
11.4%
11.4 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 who lose too much weight | 6.1% |
7.2%
1.1 pts better
|
5.4%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 7.0% · Q3 4.3% · Q4 10.9% · 4Q avg 6.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.7% |
21.6%
0.1 pts worse
|
19.6%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.7% · Q2 23.3% · Q3 19.1% · Q4 21.7% · 4Q avg 21.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.2% |
15.0%
3.8 pts better
|
16.7%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 10.3% · Q3 14.7% · Q4 9.4% · 4Q avg 11.2% · 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 | 11.7% |
21.5%
9.8 pts better
|
16.3%
4.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.7% · Q2 16.9% · 4Q avg 11.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.1% |
16.8%
9.7 pts better
|
14.9%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 7.3% · Q3 13.6% · Q4 4.7% · 4Q avg 7.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
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% · 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 | 8.9% |
21.2%
12.3 pts better
|
19.8%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 16.2% · Q3 9.8% · Q4 5.6% · 4Q avg 8.9% |
| Percentage of long-stay residents with pressure ulcers | 8.8% |
6.0%
2.8 pts worse
|
5.1%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.4% · Q2 6.3% · Q3 12.8% · Q4 7.6% · 4Q avg 8.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.5% |
79.9%
11.6 pts better
|
81.7%
9.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 87.0% · Q2 88.6% · Q3 97.7% · Q4 94.3% · 4Q avg 91.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.8% |
13.2%
0.6 pts worse
|
12.0%
1.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.8% · Observed 12.5% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 6.6% |
1.5%
5.1 pts worse
|
1.6%
5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 6.9% · Q3 11.5% · Q4 4.8% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.1% |
78.1%
13 pts better
|
79.7%
11.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.2% |
22.9%
3.7 pts better
|
23.9%
4.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.2% · Observed 16.7% · Expected 20.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-30 · Fire 2023-11-30
5 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2022-06-17 · Fire 2022-06-17
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-04-10
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 2025-06-02
E · Potential for more than minimal harm
2023-11-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-08
D · Potential for more than minimal harm
2023-11-30
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-02-08
D · Potential for more than minimal harm
2023-11-30
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-02-08
D · Potential for more than minimal harm
2023-11-30
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 2024-02-08
D · Potential for more than minimal harm
2023-11-30
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-02-08
D · Potential for more than minimal harm
2023-11-30
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-02-08
D · Potential for more than minimal harm
2023-11-30
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-02-08
D · Potential for more than minimal harm
2023-11-30
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-02-08
D · Potential for more than minimal harm
2023-11-30
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-02-08
D · Potential for more than minimal harm
2023-11-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-08
D · Potential for more than minimal harm
2022-06-17
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2022-08-28
D · Potential for more than minimal harm
2022-06-17
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 2022-08-28
D · Potential for more than minimal harm
2022-06-17
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-08-28
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-04-10
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 2025-04-25
D · Potential for more than minimal harm
2025-04-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-25
B · Minimal harm
2025-04-10
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-04-25
B · Minimal harm
2025-04-10
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2025-04-25
D · Potential for more than minimal harm
2025-01-31
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-03-07
D · Potential for more than minimal harm
2025-01-31
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-03-07
F · Potential for more than minimal harm
2023-11-30
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2023-12-20
E · Potential for more than minimal harm
2023-11-30
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-12-20
D · Potential for more than minimal harm
2023-11-30
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-09-07
G · Actual harm
2022-06-17
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 2022-07-01
G · Actual harm
2022-06-17
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-07-01
G · Actual harm
2022-06-17
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2022-07-01
F · Potential for more than minimal harm
2022-06-17
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2022-07-01
E · Potential for more than minimal harm
2022-06-17
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-07-01
E · Potential for more than minimal harm
2022-06-17
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2022-07-01
D · Potential for more than minimal harm
2022-06-17
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-07-01
D · Potential for more than minimal harm
2022-06-17
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2022-07-01
D · Potential for more than minimal harm
2022-06-17
F761 · Pharmacy Service Deficiencies
Health
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 2022-07-01
D · Potential for more than minimal harm
2022-06-17
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-07-01
B · Minimal harm
2022-06-17
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 2022-07-01
Penalties and ownership
What sits behind the stars
Ownership
Nearby options
Other facilities in reach
#1
Jesse Helms Nursing Center
Monroe, NC
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Monroe Rehabilitation Center
Monroe, NC
2-star overall rating with 2-star inspections with abuse icon flag with $76,381 in total fines with 13 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
PruittHealth-Union Pointe
Monroe, NC
1-star overall rating with 1-star inspections with $197,532 in total fines with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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