Cycle 1
Health 2025-03-28 · Fire 2025-03-28
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Mount Airy, NC
Northern Regional Hospital
5-star overall rating with 5-star inspections with 1 recent health deficiencies
830 Rockford Street, Mount Airy, NC
(336) 719-7000
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
33
Certified beds
Average residents
31
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1988-05-25
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
1.64
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.34
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.84
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
4.82
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.97
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.91
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
1.11
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
1.83
CMS adjusted RN staffing hours
Adjusted total hours
5.37
CMS adjusted total nurse staffing hours
Case-mix index
1.23
Higher values indicate more complex resident acuity
RN turnover
9%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
24%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
949
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
61.82
Composite VBP score used to determine payment impact.
Payment multiplier
1.0168
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
4.29
Baseline 17.90% · Performance 19.44% · Measure score 4.29 · Achievement 4.29 · Improvement 0
Healthcare-associated infections
6.14
Baseline 5.74% · Performance 6.00% · Measure score 6.14 · Achievement 6.14 · Improvement 0
Total nurse turnover
8.18
Baseline 20.51% · Performance 30.23% · Measure score 8.18 · Achievement 8.18 · Improvement 0
Adjusted total nurse staffing
6.11
Baseline 4.66 hours · Performance 4.82 hours · Measure score 6.11 · Achievement 6.11 · Improvement 0.90
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.02% |
10.72%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 74 · Observed rate 13.51% · Lower 95% interval 8.31% |
| Discharge to community | 60.73% |
50.57%
10.2 pts better
|
Better than the National Rate · Eligible stays 61 · Observed rate 63.93% · Lower 95% interval 52.48% |
| Medicare spending per beneficiary | 0.69 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 95.45% |
95.27%
0.2 pts better
|
Numerator 42 · Denominator 44 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 44 |
| Discharge self-care score | 51.22% |
53.69%
2.5 pts worse
|
Numerator 21 · Denominator 41 |
| Discharge mobility score | 46.34% |
50.94%
4.6 pts worse
|
Numerator 19 · Denominator 41 |
| Pressure ulcers or injuries, new or worsened | 13.64% |
2.29%
11.4 pts worse
|
Numerator 6 · Denominator 44 · Adjusted rate 18.09% |
| Healthcare-associated infections requiring hospitalization | 6% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 42 · Observed rate 0% · Lower 95% interval 3.06% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 83 |
| Staff flu vaccination coverage | 95.18% |
42%
53.2 pts better
|
Numerator 79 · Denominator 83 |
| Discharge function score | 36.59% |
56.45%
19.9 pts worse
|
Numerator 15 · Denominator 41 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 29 · Denominator 29 |
| 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 | 12.5% |
25.2%
12.7 pts worse
|
Numerator 3 · Denominator 24 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 95.3% |
91.5%
3.8 pts better
|
93.4%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 92.6% · Q2 92.6% · Q3 96.0% · Q4 100.0% · 4Q avg 95.3% |
| 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 | 1.9% |
3.6%
1.7 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.0% · Q4 3.7% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 8.8% |
4.8%
4 pts worse
|
11.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.4% · Q2 15.4% · Q3 4.2% · Q4 8.0% · 4Q avg 8.8% |
| Percentage of long-stay residents who lose too much weight | 6.3% |
7.2%
0.9 pts better
|
5.4%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.5% · Q4 5.0% · 4Q avg 6.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 30.9% |
21.6%
9.3 pts worse
|
19.6%
11.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.8% · Q2 35.0% · Q4 25.0% · 4Q avg 30.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 6.8% |
15.0%
8.2 pts better
|
16.7%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · 4Q avg 6.8% · 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 | 17.3% |
21.5%
4.2 pts better
|
16.3%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 20.5% |
16.8%
3.7 pts worse
|
14.9%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.3% · 4Q avg 20.5% · 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 1.9% · Q2 1.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 12.5% |
2.6%
9.9 pts worse
|
1.7%
10.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.6% · Q2 3.8% · Q3 8.3% · Q4 7.4% · 4Q avg 12.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.3% |
21.2%
5.9 pts better
|
19.8%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 13.4% · Q3 12.5% · Q4 29.9% · 4Q avg 15.3% |
| Percentage of long-stay residents with pressure ulcers | 10.6% |
6.0%
4.6 pts worse
|
5.1%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 13.6% · Q3 10.1% · Q4 5.4% · 4Q avg 10.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.7% |
79.9%
13.8 pts better
|
81.7%
12 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 88.1% · Q2 95.0% · Q3 95.8% · Q4 95.6% · 4Q avg 93.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.2% |
13.2%
3 pts better
|
12.0%
1.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.2% · Observed 8.1% · Expected 8.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short 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 short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.9% |
78.1%
14.8 pts better
|
79.7%
13.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 3.9% |
22.9%
19 pts better
|
23.9%
20 pts better
|
Short Stay · 20240701-20250630 · Adjusted 3.9% · Observed 2.7% · Expected 16.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-05 · Fire 2024-01-05
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-12-01 · Fire 2022-12-01
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-03-28
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 2025-04-17
Penalties and ownership
What sits behind the stars
Ownership
Atkins, Daron
Corporate Director · Individual
Carter, Dwayne
Corporate Director · Individual
Cook, Phillip
Corporate Director · Individual
Gillespie, David
Corporate Director · Individual
Golding, Ruben
Corporate Director · Individual
Hickling, Andrea
Corporate Officer · Individual
Hickling, Andrea
Contracted Managing Employee · Individual
Hill, Earl
Corporate Officer · Individual
Hill, Earl
Contracted Managing Employee · Individual
Lewis, Teresa
Corporate Director · Individual
Moody, Robert
Corporate Director · Individual
Patterson, Paul
Corporate Director · Individual
Riggs, Tommy
Corporate Director · Individual
Shockley, David
Corporate Director · Individual
Snow, Phillip
Corporate Director · Individual
Venable, Monty
Corporate Director · Individual
White, Derek
Operational/Managerial Control · Individual
Woltz, William
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Central Continuing Care
Mount Airy, NC
4-star overall rating with 4-star inspections with $5,597 in total fines with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Surry Community Health Center by Harborview
Mount Airy, NC
1-star overall rating with 1-star inspections with $145,262 in total fines with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Chatham Nursing & Rehabilitation
Elkin, NC
5-star overall rating with 5-star inspections with 3 fire-safety deficiencies in the latest cycle
Jump out