Cycle 1
Health 2025-12-10 · Fire 2024-08-21
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Spencer, NC
Compass Healthcare and Rehab Rowan, LLC
1-star overall rating with 3-star inspections with $10,039 in total fines with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1404 S Salisbury Avenue, Spencer, NC
(704) 633-3892
Overall
1 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
70
Certified beds
Average residents
63
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1988-08-11
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
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
0.39
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.84
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
1.85
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.08
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.23
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
2.40
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.25
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.37
CMS adjusted RN staffing hours
Adjusted total hours
2.87
CMS adjusted total nurse staffing hours
Case-mix index
1.47
Higher values indicate more complex resident acuity
RN turnover
22%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,402
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.87
Composite VBP score used to determine payment impact.
Payment multiplier
0.9843
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.89
Performance 20.56% · Measure score 1.89 · Achievement 1.89 · This facility did not have sufficient data to calculate a baseline period measure result.
Healthcare-associated infections
0
Performance 9.27% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Total nurse turnover
8.86
Baseline 52.78% · Performance 27.45% · Measure score 8.86 · Achievement 8.86 · Improvement 8.57
Adjusted total nurse staffing
0
Baseline 2.80 hours · Performance 2.85 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.73% |
10.72%
1 pts worse
|
No Different than the National Rate · Eligible stays 54 · Observed rate 14.81% · Lower 95% interval 8.22% |
| Discharge to community | 40.81% |
50.57%
9.8 pts worse
|
No Different than the National Rate · Eligible stays 32 · Observed rate 31.25% · Lower 95% interval 27.04% |
| Medicare spending per beneficiary | 1.32 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 92.59% |
95.27%
2.7 pts worse
|
Numerator 25 · Denominator 27 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 27 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 14.81% |
2.29%
12.5 pts worse
|
Numerator 4 · Denominator 27 · Adjusted rate 9.85% |
| Healthcare-associated infections requiring hospitalization | 9.27% |
7.12%
2.1 pts worse
|
No Different than the National Rate · Eligible stays 41 · Observed rate 17.07% · Lower 95% interval 5.23% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 65 |
| Staff flu vaccination coverage | 15.15% |
42%
26.9 pts worse
|
Numerator 10 · Denominator 66 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.4 |
1.8
0.6 pts worse
|
1.9
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 1.9 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.8
0.8 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.9 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.9% |
91.5%
6.4 pts better
|
93.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 94.7% · Q2 98.4% · Q3 100.0% · Q4 98.3% · 4Q avg 97.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.5% |
94.1%
4.4 pts better
|
95.5%
3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.1% |
3.6%
1.5 pts better
|
3.3%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 4.8% · Q3 0.0% · Q4 0.0% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.2% |
4.8%
2.6 pts better
|
11.4%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 3.3% · Q3 1.8% · Q4 1.7% · 4Q avg 2.2% |
| Percentage of long-stay residents who lose too much weight | 5.1% |
7.2%
2.1 pts better
|
5.4%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 5.3% · Q3 7.5% · Q4 3.6% · 4Q avg 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.3% |
21.6%
5.7 pts worse
|
19.6%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.5% · Q2 28.1% · Q3 25.9% · Q4 29.3% · 4Q avg 27.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.0% |
15.0%
6 pts worse
|
16.7%
4.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 20.5% · Q3 20.5% · Q4 22.9% · 4Q avg 21.0% · 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 | 34.6% |
21.5%
13.1 pts worse
|
16.3%
18.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 34.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 26.0% |
16.8%
9.2 pts worse
|
14.9%
11.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.8% · Q2 22.0% · Q3 20.0% · Q4 25.5% · 4Q avg 26.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.6% |
0.9%
0.7 pts worse
|
1.0%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 2.1% · Q3 0.0% · Q4 3.1% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.3% |
2.6%
1.3 pts better
|
1.7%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.0% · Q3 1.7% · Q4 1.8% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.7% |
21.2%
3.5 pts better
|
19.8%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 28.5% · Q3 6.2% · Q4 25.0% · 4Q avg 17.7% |
| Percentage of long-stay residents with pressure ulcers | 2.4% |
6.0%
3.6 pts better
|
5.1%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 1.9% · Q3 2.1% · Q4 3.6% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 76.5% |
79.9%
3.4 pts worse
|
81.7%
5.2 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 63.6% · Q3 95.0% · Q4 71.4% · 4Q avg 76.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 22.1% |
13.2%
8.9 pts worse
|
12.0%
10.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 22.1% · Observed 21.7% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 5.6% |
1.5%
4.1 pts worse
|
1.6%
4 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 5.6% · Used in QM five-star |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.5% |
22.9%
4.4 pts better
|
23.9%
5.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.5% · Observed 17.4% · Expected 22.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-21 · Fire 2023-10-11
3 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-10-11 · Fire 2022-04-28
4 health deficiencies
Top issue: Nursing and Physician Services (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-08-21
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 2024-10-11
D · Potential for more than minimal harm
2024-08-21
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-10-11
D · Potential for more than minimal harm
2023-10-11
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-11-10
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-10
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2025-12-30
D · Potential for more than minimal harm
2025-12-10
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 2025-12-30
J · Immediate jeopardy
2024-08-21
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-09-13
E · Potential for more than minimal harm
2024-08-21
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 2024-09-13
D · Potential for more than minimal harm
2024-08-21
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-09-13
F · Potential for more than minimal harm
2023-10-11
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 2023-11-03
D · Potential for more than minimal harm
2023-10-11
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-11-03
B · Minimal harm
2023-10-11
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-11-03
B · Minimal harm
2023-10-11
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-11-03
Penalties and ownership
What sits behind the stars
$10,039
2024-08-21
Fine
Fine · fine $10,039
Fine
Ownership
Nunn, Todd
5% Or Greater Direct Ownership Interest · Individual
Nunn, Todd
Operational/Managerial Control · Individual
Nunn, Todd
Corporate Officer · Individual
Nearby options
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3-star overall rating with 3-star inspections with $8,738 in total fines with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
NC State Veterans Home - Salisbury
Salisbury, NC
3-star overall rating with 2-star inspections with $19,145 in total fines with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Piedmont Health & Rehab Center
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3-star overall rating with 3-star inspections with $8,512 in total fines with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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