Cycle 1
Health 2025-01-08 · Fire 2025-01-08
13 health deficiencies
Top issue: Resident Rights (4 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Monroe, NC
Monroe Rehabilitation Center
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
1212 Sunset Drive East, Monroe, NC
(704) 283-8548
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
147
Certified beds
Average residents
112
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Sovereign Healthcare Holdings
Operator or chain grouping
Approved since
1986-12-30
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
43 facilities
Chain averages 4 overall / 3 health / 3 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
0.48
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.89
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.23
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.60
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.37
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.17
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.53
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.18
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.52
CMS adjusted RN staffing hours
Adjusted total hours
3.92
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
52%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,952
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.21
Composite VBP score used to determine payment impact.
Payment multiplier
0.9864
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.89% · Performance 21.59% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
6.24
Baseline 8.37% · Performance 6.10% · Measure score 6.24 · Achievement 5.81 · Improvement 6.24
Total nurse turnover
2.68
Baseline 47.17% · Performance 52.73% · Measure score 2.68 · Achievement 2.68 · Improvement 0
Adjusted total nurse staffing
3.57
Baseline 3.77 hours · Performance 4.09 hours · Measure score 3.57 · Achievement 3.57 · Improvement 1.08
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.19% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 99 · Observed rate 13.13% · Lower 95% interval 7.88% |
| Discharge to community | 45.34% |
50.57%
5.2 pts worse
|
No Different than the National Rate · Eligible stays 94 · Observed rate 37.23% · Lower 95% interval 35.13% |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 97.1% |
95.27%
1.8 pts better
|
Numerator 67 · Denominator 69 |
| Falls with major injury | 1.45% |
0.77%
0.7 pts worse
|
Numerator 1 · Denominator 69 |
| Discharge self-care score | 69.05% |
53.69%
15.4 pts better
|
Numerator 29 · Denominator 42 |
| Discharge mobility score | 54.76% |
50.94%
3.8 pts better
|
Numerator 23 · Denominator 42 |
| Pressure ulcers or injuries, new or worsened | 11.76% |
2.29%
9.5 pts worse
|
Numerator 8 · Denominator 68 · Adjusted rate 10.77% |
| Healthcare-associated infections requiring hospitalization | 6.1% |
7.12%
1 pts better
|
No Different than the National Rate · Eligible stays 52 · Observed rate 3.85% · Lower 95% interval 3.66% |
| Staff COVID-19 vaccination coverage | 6.21% |
8.2%
2 pts worse
|
Numerator 9 · Denominator 145 |
| Staff flu vaccination coverage | 23.14% |
42%
18.9 pts worse
|
Numerator 53 · Denominator 229 |
| Discharge function score | 66.67% |
56.45%
10.2 pts better
|
Numerator 28 · Denominator 42 |
| Transfer of health information to provider | 82.05% |
95.95%
13.9 pts worse
|
Numerator 32 · Denominator 39 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 12.5% |
25.2%
12.7 pts worse
|
Numerator 4 · Denominator 32 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.8
About the same
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 2.0 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
1.8
0.6 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.2 · Expected 1.7 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
91.5%
8.3 pts better
|
93.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 99.0% · Q4 100.0% · 4Q avg 99.8% |
| 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 | 4.2% |
3.6%
0.6 pts worse
|
3.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 3.7% · Q3 5.2% · Q4 4.0% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 11.5% |
4.8%
6.7 pts worse
|
11.4%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 17.0% · Q3 6.0% · Q4 13.2% · 4Q avg 11.5% |
| Percentage of long-stay residents who lose too much weight | 10.1% |
7.2%
2.9 pts worse
|
5.4%
4.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 16.3% · Q3 12.2% · Q4 2.2% · 4Q avg 10.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 6.9% |
21.6%
14.7 pts better
|
19.6%
12.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 4.8% · Q3 7.7% · Q4 7.4% · 4Q avg 6.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.7% |
15.0%
7.7 pts worse
|
16.7%
6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.0% · Q2 24.7% · Q3 20.7% · Q4 18.1% · 4Q avg 22.7% · 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 | 15.9% |
21.5%
5.6 pts better
|
16.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 20.3% · Q3 20.4% · Q4 7.3% · 4Q avg 15.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.4% |
16.8%
4.4 pts better
|
14.9%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 17.2% · Q3 10.1% · Q4 7.0% · 4Q avg 12.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.9%
0.5 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
2.6%
1.8 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 0.0% · Q3 1.1% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 10.8% |
21.2%
10.4 pts better
|
19.8%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.8% · Q2 12.7% · Q3 15.9% · Q4 7.0% · 4Q avg 10.8% |
| Percentage of long-stay residents with pressure ulcers | 8.2% |
6.0%
2.2 pts worse
|
5.1%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.3% · Q2 11.5% · Q3 11.5% · Q4 3.3% · 4Q avg 8.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.9% |
79.9%
17 pts better
|
81.7%
15.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.6% · Q2 98.0% · Q3 99.1% · Q4 92.8% · 4Q avg 96.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 14.0% |
13.2%
0.8 pts worse
|
12.0%
2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 14.0% · Observed 13.6% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 7.0% |
1.5%
5.5 pts worse
|
1.6%
5.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 10.0% · Q2 6.5% · Q3 5.1% · Q4 7.1% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.2% |
78.1%
15.1 pts better
|
79.7%
13.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.1% |
22.9%
2.8 pts better
|
23.9%
3.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.1% · Observed 19.7% · Expected 23.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-06-08 · Fire 2023-06-08
7 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2021-10-26 · Fire 2021-10-26
12 health deficiencies
Top issue: Infection Control (3 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-01-08
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-01-08
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 2025-04-11
D · Potential for more than minimal harm
2025-01-08
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-04-11
D · Potential for more than minimal harm
2025-01-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-29
D · Potential for more than minimal harm
2025-01-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-29
F · Potential for more than minimal harm
2023-06-08
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-10-11
F · Potential for more than minimal harm
2023-06-08
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-10-11
F · Potential for more than minimal harm
2023-06-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-11
F · Potential for more than minimal harm
2023-06-08
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-10-11
F · Potential for more than minimal harm
2023-06-08
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2023-10-11
F · Potential for more than minimal harm
2023-06-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-10-11
E · Potential for more than minimal harm
2023-06-08
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-10-11
D · Potential for more than minimal harm
2021-10-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-01-04
Inspection history
Recent health citations
G · Actual harm
2025-09-30
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-10-01
E · Potential for more than minimal harm
2025-09-30
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-10-01
D · Potential for more than minimal harm
2025-09-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-08
J · Immediate jeopardy
2025-04-17
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 2025-04-10
G · Actual harm
2025-01-08
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-11-02
E · Potential for more than minimal harm
2025-01-08
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 2025-02-10
E · Potential for more than minimal harm
2025-01-08
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 2025-02-10
D · Potential for more than minimal harm
2025-01-08
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 2025-02-10
D · Potential for more than minimal harm
2025-01-08
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-02-10
D · Potential for more than minimal harm
2025-01-08
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 2025-02-10
D · Potential for more than minimal harm
2025-01-08
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-02-10
C · Minimal harm
2025-01-08
F575 · Resident Rights Deficiencies
Health
Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.
Corrected 2025-02-10
B · Minimal harm
2025-01-08
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 2025-02-10
E · Potential for more than minimal harm
2023-06-08
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-07-06
E · Potential for more than minimal harm
2023-06-08
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-07-06
E · Potential for more than minimal harm
2023-06-08
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2023-07-06
D · Potential for more than minimal harm
2023-06-08
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 2023-07-06
D · Potential for more than minimal harm
2023-06-08
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 2023-07-06
B · Minimal harm
2023-06-08
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 2023-07-06
B · Minimal harm
2023-06-08
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 2023-07-06
F · Potential for more than minimal harm
2021-10-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-12-06
F · Potential for more than minimal harm
2021-10-26
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2021-12-06
E · Potential for more than minimal harm
2021-10-26
F563 · Resident Rights Deficiencies
Health
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Corrected 2021-12-06
E · Potential for more than minimal harm
2021-10-26
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 2021-12-06
E · Potential for more than minimal harm
2021-10-26
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 2021-12-06
E · Potential for more than minimal harm
2021-10-26
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2021-12-06
D · Potential for more than minimal harm
2021-10-26
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2021-12-06
D · Potential for more than minimal harm
2021-10-26
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2021-12-06
D · Potential for more than minimal harm
2021-10-26
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2021-12-06
D · Potential for more than minimal harm
2021-10-26
F726 · Nursing and Physician Services Deficiencies
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 2021-12-06
D · Potential for more than minimal harm
2021-10-26
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2021-12-06
C · Minimal harm
2021-10-26
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2021-12-06
Penalties and ownership
What sits behind the stars
$43,450
2025-09-30
Fine
Fine · fine $43,450
Fine
$16,985
2025-04-17
Fine
Fine · fine $16,985
Fine
$4,246
2025-01-22
Fine
Fine · fine $4,246
Fine
$0
2025-01-22
Payment Denial
Payment Denial · denial start 2025-04-22 · 7 days
7 day denial
$11,700
2025-01-08
Fine
Fine · fine $11,700
Fine
Ownership
Cronquist, Royce
Operational/Managerial Control · Individual
Hsp Carolina, LLC
5% Or Greater Security Interest · Organization
Karstetter, Bryce
Operational/Managerial Control · Individual
Kelly, Michelle
Operational/Managerial Control · Individual
Lee, Min-Ji
Operational/Managerial Control · Individual
Mangine, John
Operational/Managerial Control · Individual
Melton, Donald
Operational/Managerial Control · Individual
Southern Healthcare Management LLC
Operational/Managerial Control · Organization
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
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
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