Cycle 1
Health 2025-08-14 · Fire 2024-05-09
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Monroe, NC
Jesse Helms Nursing Center
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1411 Dove Street, Monroe, NC
(980) 993-3280
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
70
Certified beds
Average residents
63
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Atrium Health
Operator or chain grouping
Approved since
1973-06-18
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
6 facilities
Chain averages 4 overall / 3 health / 4 staffing / 4 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
0.52
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
1.23
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.09
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.84
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.75
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.81
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.48
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.50
CMS adjusted RN staffing hours
Adjusted total hours
3.71
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
13%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
26%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,662
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.07
Composite VBP score used to determine payment impact.
Payment multiplier
0.9840
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.52
Baseline 19.77% · Performance 20.72% · Measure score 1.52 · Achievement 1.52 · Improvement 0
Healthcare-associated infections
1.79
Baseline 5.56% · Performance 7.30% · Measure score 1.79 · Achievement 1.79 · Improvement 0
Total nurse turnover
5.04
Baseline 48.00% · Performance 43.08% · Measure score 5.04 · Achievement 5.04 · Improvement 1.63
Adjusted total nurse staffing
2.08
Baseline 4.40 hours · Performance 3.67 hours · Measure score 2.08 · Achievement 2.08 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.21% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 106 · Observed rate 7.55% · Lower 95% interval 7.49% |
| Discharge to community | 59.58% |
50.57%
9 pts better
|
No Different than the National Rate · Eligible stays 103 · Observed rate 59.22% · Lower 95% interval 49.99% |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 97.47% |
95.27%
2.2 pts better
|
Numerator 77 · Denominator 79 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 79 |
| Discharge self-care score | 40.68% |
53.69%
13 pts worse
|
Numerator 24 · Denominator 59 |
| Discharge mobility score | 44.07% |
50.94%
6.9 pts worse
|
Numerator 26 · Denominator 59 |
| Pressure ulcers or injuries, new or worsened | 7.59% |
2.29%
5.3 pts worse
|
Numerator 6 · Denominator 79 · Adjusted rate 7.71% |
| Healthcare-associated infections requiring hospitalization | 7.3% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 73 · Observed rate 6.85% · Lower 95% interval 4.07% |
| Staff COVID-19 vaccination coverage | 2.44% |
8.2%
5.8 pts worse
|
Numerator 1 · Denominator 41 |
| Staff flu vaccination coverage | 94.37% |
42%
52.4 pts better
|
Numerator 67 · Denominator 71 |
| Discharge function score | 47.46% |
56.45%
9 pts worse
|
Numerator 28 · Denominator 59 |
| Transfer of health information to provider | 56.14% |
95.95%
39.8 pts worse
|
Numerator 32 · Denominator 57 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 17.5% |
25.2%
7.7 pts worse
|
Numerator 7 · Denominator 40 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 70.8% |
91.5%
20.7 pts worse
|
93.4%
22.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 71.4% · Q2 63.8% · Q3 72.3% · Q4 75.5% · 4Q avg 70.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.0% |
94.1%
3.9 pts better
|
95.5%
2.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.6% |
3.6%
1 pts better
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.1% · Q3 4.3% · Q4 4.1% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.7% |
4.8%
4.9 pts worse
|
11.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 15.9% · Q3 11.9% · Q4 6.8% · 4Q avg 9.7% |
| 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 7.0% · Q2 20.0% · Q3 5.3% · Q4 2.3% · 4Q avg 8.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.3% |
21.6%
6.3 pts better
|
19.6%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 16.7% · Q3 15.6% · Q4 19.1% · 4Q avg 15.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.1% |
15.0%
11.9 pts better
|
16.7%
13.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 0.0% · Q3 0.0% · Q4 8.6% · 4Q avg 3.1% · 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 | 14.6% |
21.5%
6.9 pts better
|
16.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.6% · 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 16.7% · Q2 22.6% · Q3 34.6% · 4Q avg 26.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
0.9%
About the same
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 1.4% · Q4 1.1% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
2.6%
1 pts better
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 0.0% · Q3 2.2% · Q4 2.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 35.1% |
21.2%
13.9 pts worse
|
19.8%
15.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.2% · Q2 39.8% · Q3 34.7% · Q4 37.0% · 4Q avg 35.1% |
| Percentage of long-stay residents with pressure ulcers | 15.2% |
6.0%
9.2 pts worse
|
5.1%
10.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 14.9% · Q3 13.0% · Q4 21.9% · 4Q avg 15.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 90.2% |
79.9%
10.3 pts better
|
81.7%
8.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.5% · Q2 88.8% · Q3 87.7% · Q4 94.5% · 4Q avg 90.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.4% |
13.2%
7.8 pts better
|
12.0%
6.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.4% · Observed 4.9% · Expected 10.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.5%
0.3 pts better
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 1.3% · Q4 1.3% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.2% |
78.1%
17.1 pts better
|
79.7%
15.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.3% |
22.9%
1.6 pts better
|
23.9%
2.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.3% · Observed 17.3% · Expected 19.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-09 · Fire 2022-12-15
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-12-15 · Fire 2021-06-10
3 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
1 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-05-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-06-25
D · Potential for more than minimal harm
2022-12-15
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-02-24
D · Potential for more than minimal harm
2022-12-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-24
D · Potential for more than minimal harm
2021-06-10
K111 · Construction Deficiencies
Fire Safety
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Corrected 2021-08-06
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-14
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 2025-09-11
D · Potential for more than minimal harm
2025-08-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-11
E · Potential for more than minimal harm
2022-12-15
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 2023-01-12
D · Potential for more than minimal harm
2022-12-15
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2023-01-12
B · Minimal harm
2022-12-15
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-01-12
Penalties and ownership
What sits behind the stars
Ownership
Advocate Health Inc
Operational/Managerial Control · Organization
Atrium Health Inc
Operational/Managerial Control · Organization
Ball, Rodney
Corporate Officer · Individual
Broad River Rehabilitation
Operational/Managerial Control · Organization
Haynes, Kenneth
Corporate Officer · Individual
Pro Diversity Partners, LLC
Operational/Managerial Control · Organization
Saeed, Maryam
Operational/Managerial Control · Individual
Scotland, Linden
Operational/Managerial Control · Individual
The Charlotte-Mecklenburg Hospital Authority
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
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
#2
Accordius Health at Monroe
Monroe, NC
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 1 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
Jump out