Cycle 1
Health 2025-01-09 · Fire 2025-01-09
1 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Statesville, NC
Iredell Memorial Hospital Inc
5-star overall rating with 5-star inspections with 1 recent health deficiencies
557 Brookdale Drive, Statesville, NC
(704) 878-4541
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
48
Certified beds
Average residents
101
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1989-07-13
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
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
0.74
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.54
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
0.79
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
2.07
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.27
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
1.78
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.76
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
0.81
CMS adjusted RN staffing hours
Adjusted total hours
2.26
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
30%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
896
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
62.39
Composite VBP score used to determine payment impact.
Payment multiplier
1.0173
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.47
Baseline 18.45% · Performance 20.29% · Measure score 2.47 · Achievement 2.47 · Improvement 0
Healthcare-associated infections
2.48
Baseline 4.84% · Performance 7.09% · Measure score 2.48 · Achievement 2.48 · Improvement 0
Total nurse turnover
10
Baseline 20.76% · Performance 23.21% · Measure score 10 · Achievement 10 · Improvement 0
Adjusted total nurse staffing
10
Baseline 5.59 hours · Performance 7.15 hours · Measure score 10 · Achievement 10 · Improvement 9
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.34% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 346 · Observed rate 9.25% · Lower 95% interval 8.11% |
| Discharge to community | 67.17% |
50.57%
16.6 pts better
|
Better than the National Rate · Eligible stays 331 · Observed rate 66.47% · Lower 95% interval 61.69% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 75.8% |
95.27%
19.5 pts worse
|
Numerator 119 · Denominator 157 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 157 |
| Discharge self-care score | 61.11% |
53.69%
7.4 pts better
|
Numerator 77 · Denominator 126 |
| Discharge mobility score | 56.35% |
50.94%
5.4 pts better
|
Numerator 71 · Denominator 126 |
| Pressure ulcers or injuries, new or worsened | 5.1% |
2.29%
2.8 pts worse
|
Numerator 8 · Denominator 157 · Adjusted rate 6.1% |
| Healthcare-associated infections requiring hospitalization | 7.09% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 195 · Observed rate 6.15% · Lower 95% interval 4.62% |
| Staff COVID-19 vaccination coverage | 22.54% |
8.2%
14.3 pts better
|
Numerator 16 · Denominator 71 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 48.41% |
56.45%
8 pts worse
|
Numerator 61 · Denominator 126 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 33 · Denominator 33 |
| Transfer of health information to patient | 93.33% |
96.28%
3 pts worse
|
Numerator 112 · Denominator 120 |
| Resident COVID-19 vaccinations up to date | 20.63% |
25.2%
4.6 pts worse
|
Numerator 13 · Denominator 63 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.6% |
91.5%
5.1 pts better
|
93.4%
3.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 96.8% · 4Q avg 96.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.7% |
3.6%
1.9 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 0.0% · 4Q avg 1.7% · 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 · Q3 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 12.1% |
21.6%
9.5 pts better
|
19.6%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 16.1% · 4Q avg 12.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.4% |
15.0%
9.6 pts better
|
16.7%
11.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 9.1% · 4Q avg 5.4% · 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 · Q3 0.0% · 4Q avg 0.0% |
| 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 23.8% |
2.6%
21.2 pts worse
|
1.7%
22.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 23.8% · Used in QM five-star |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
6.0%
6 pts better
|
5.1%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 85.8% |
79.9%
5.9 pts better
|
81.7%
4.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.8% · Q2 91.9% · Q3 75.4% · Q4 78.5% · 4Q avg 85.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 3.7% |
13.2%
9.5 pts better
|
12.0%
8.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 3.7% · Observed 3.3% · Expected 9.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.7% |
1.5%
2.2 pts worse
|
1.6%
2.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 2.7% · Q3 2.2% · Q4 4.1% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 86.2% |
78.1%
8.1 pts better
|
79.7%
6.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 86.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.0% |
22.9%
6.1 pts worse
|
23.9%
5.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.0% · Observed 22.4% · Expected 18.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-27 · Fire 2023-10-27
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-07-22 · Fire 2022-07-22
2 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
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
2023-10-27
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-02-14
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-01-09
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2025-02-10
D · Potential for more than minimal harm
2023-10-27
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-11-13
C · Minimal harm
2022-07-22
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2022-08-04
B · Minimal harm
2022-07-22
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2022-08-04
Penalties and ownership
What sits behind the stars
Ownership
Smith, Gary
Operational/Managerial Control · Individual
Smith, Gary
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Autumn Care of Statesville
Statesville, NC
3-star overall rating with 4-star inspections with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
The Greens at Maple Leaf
Statesville, NC
3-star overall rating with 2-star inspections with $23,835 in total fines with 4 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Accordius Health at Mooresville
Mooresville, NC
1-star overall rating with 1-star inspections with $157,297 in total fines with 8 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
Jump out