8 health deficiencies
Top issue: Nursing and Physician Services (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Hertford, NC
1-star overall rating with 2-star inspections with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1300 Don Juan Road, Hertford, NC
(252) 426-5391
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Beds
78
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
1987-07-24
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
RN hours / resident day
0.47
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.77
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
1.91
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.15
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.24
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
2.59
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.32
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.47
CMS adjusted RN staffing hours
Adjusted total hours
3.13
CMS adjusted total nurse staffing hours
Case-mix index
1.37
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
72%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Program rank
13,526
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
4.05
Composite VBP score used to determine payment impact.
Payment multiplier
0.9805
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
1.62
Baseline 18.04% · Performance 20.68% · Measure score 1.62 · Achievement 1.62 · Improvement 0
Healthcare-associated infections
0
Baseline 5.49% · Performance 7.87% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Performance 73.13% · Measure score 0 · Achievement 0 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 3.79 hours · Performance 2.90 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.8% |
10.72%
2.1 pts worse
|
No Different than the National Rate · Eligible stays 88 · Observed rate 18.18% · Lower 95% interval 9.1% |
| Discharge to community | 36.93% |
50.57%
13.6 pts worse
|
Worse than the National Rate · Eligible stays 74 · Observed rate 28.38% · Lower 95% interval 28.43% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 67 · Denominator 67 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 67 |
| Discharge self-care score | 52.27% |
53.69%
1.4 pts worse
|
Numerator 23 · Denominator 44 |
| Discharge mobility score | 54.55% |
50.94%
3.6 pts better
|
Numerator 24 · Denominator 44 |
| Pressure ulcers or injuries, new or worsened | 11.94% |
2.29%
9.6 pts worse
|
Numerator 8 · Denominator 67 · Adjusted rate 11.29% |
| Healthcare-associated infections requiring hospitalization | 7.87% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 55 · Observed rate 10.91% · Lower 95% interval 4.8% |
| Staff COVID-19 vaccination coverage | 60.61% |
8.2%
52.4 pts better
|
Numerator 40 · Denominator 66 |
| Staff flu vaccination coverage | 1.32% |
42%
40.7 pts worse
|
Numerator 1 · Denominator 76 |
| Discharge function score | 56.82% |
56.45%
0.4 pts better
|
Numerator 25 · Denominator 44 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 32 · Denominator 32 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 36.11% |
25.2%
10.9 pts better
|
Numerator 13 · Denominator 36 |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.3 |
1.8
0.5 pts better
|
1.9
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.6 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.6 |
1.8
0.8 pts worse
|
1.8
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.6 · Observed 2.7 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
91.5%
8.1 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 98.2% · 4Q avg 99.6% |
| 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 | 0.0% |
3.6%
3.6 pts better
|
3.3%
3.3 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 who have depressive symptoms | 0.9% |
4.8%
3.9 pts better
|
11.4%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% |
| Percentage of long-stay residents who lose too much weight | 3.2% |
7.2%
4 pts better
|
5.4%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 0.0% · Q3 0.0% · Q4 5.9% · 4Q avg 3.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.3% |
21.6%
1.3 pts better
|
19.6%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.4% · Q2 20.7% · Q3 15.8% · Q4 18.9% · 4Q avg 20.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.4% |
15.0%
2.6 pts better
|
16.7%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 12.2% · Q3 13.2% · Q4 6.2% · 4Q avg 12.4% · 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 | 24.2% |
21.5%
2.7 pts worse
|
16.3%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 24.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.8% |
16.8%
3 pts worse
|
14.9%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.4% · Q2 9.3% · Q3 13.2% · Q4 28.6% · 4Q avg 19.8% · 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 | 3.9% |
2.6%
1.3 pts worse
|
1.7%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 1.7% · Q3 3.4% · Q4 7.5% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 11.0% |
21.2%
10.2 pts better
|
19.8%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 5.3% · Q3 12.3% · Q4 20.9% · 4Q avg 11.0% |
| Percentage of long-stay residents with pressure ulcers | 7.1% |
6.0%
1.1 pts worse
|
5.1%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 7.0% · Q3 4.8% · Q4 7.2% · 4Q avg 7.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.4% |
79.9%
16.5 pts better
|
81.7%
14.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.2% · Q3 98.0% · Q4 88.5% · 4Q avg 96.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 24.1% |
13.2%
10.9 pts worse
|
12.0%
12.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.1% · Observed 24.3% · Expected 11.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
1.5%
0.1 pts worse
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.3% · Q4 3.3% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.3% |
78.1%
9.2 pts better
|
79.7%
7.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.9% |
22.9%
5 pts worse
|
23.9%
4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.9% · Observed 27.0% · Expected 23.1% · Used in QM five-star |
Survey summary
Top issue: Nursing and Physician Services (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Top issue: Quality of Life and Care (3 deficiencies)
14 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Top issue: Quality of Life and Care (6 deficiencies)
9 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-07-11
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-07-11
Fire Safety
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Corrected 2024-08-05
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-08-05
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 2024-08-05
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-08-05
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-08-05
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-08-05
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-08-05
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-08-05
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-08-05
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-08-05
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-08-05
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-08-05
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-08-05
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-08-05
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2023-02-22
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-03-31
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-03-31
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-03-31
Fire Safety
Use approved construction type or materials.
Corrected 2023-03-31
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-03-31
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-03-31
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-03-31
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-03-31
Inspection history
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 2025-07-01
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2025-07-01
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-07-01
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-07-01
Health
Provide activities to meet all resident's needs.
Corrected 2025-07-01
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-07-01
Health
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Corrected 2025-07-01
Health
Post nurse staffing information every day.
Corrected 2025-07-01
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 2024-06-09
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 2024-06-09
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-06-09
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-06-09
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-06-09
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-06-09
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-06-09
Health
Provide and implement an infection prevention and control program.
Corrected 2024-06-09
Health
Post nurse staffing information every day.
Corrected 2024-06-09
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-06-09
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 2024-06-09
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2023-06-19
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-02-22
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-02-22
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-02-22
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 2023-02-22
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-02-22
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 2023-02-22
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-02-22
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-02-22
Health
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.
Corrected 2023-02-22
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 2023-02-22
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 2023-02-22
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-02-22
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-02-22
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-02-22
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-02-22
Health
Provide and implement an infection prevention and control program.
Corrected 2023-02-22
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2023-02-22
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2023-02-22
Health
Ensure the activities program is directed by a qualified professional.
Corrected 2023-02-22
Health
Post nurse staffing information every day.
Corrected 2023-02-22
Penalties and ownership
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Corporate Director · Individual
W-2 Managing Employee · Individual
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