Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

Stratford Manor Health & Rehab

Monroe, NC · 60 certified beds · Last Life Safety survey April 10, 2025

CMS Certification Number 345345 · first certified January 1991

Ownership

Independently operated (no chain recorded by CMS) · For profit - Limited Liability company

Ownership changed February 1, 2019 (change of ownership)to ACCORDIUS HEALTH AT MONROE LLC from SSC MONROE OPERATING COMPANY LLC

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within NC

14 citations — more than 71% of the 419 certified nursing homes in NC. Compared within NC rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 1 citation; the earlier surveys in the window averaged 6.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

Well past the typical window (June 2026 to August 2026), and past the point by which nine in ten NC facilities have been surveyed. This facility’s last Life Safety survey was April 2025. Facilities in NC are typically surveyed 14–16 months after the last one (median 15), measured over 412 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Physical environment (health survey)

4 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 14 Life Safety citations above. The Physical Environment Index

F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F-0880 Provide and implement an infection prevention and control program.
F-0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

How that compares

Citations on file over three years

Compared with the median facility in NC, and nationally. Surveyors differ markedly between states, so the NC figure is the meaningful one.

Citations on file over three years, compared
Measure	Citations
This facility	14
Median facility in NC	9
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
June 17, 2022	3
November 30, 2023	10
April 10, 2025	1

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	3	2025-04-10
K-0521	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	2	2023-11-30
K-0511	Have properly installed electrical wiring and gas equipment.	1	2023-11-30
K-0363	Install corridor and hallway doors that block smoke.	1	2023-11-30
K-0222	Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.	1	2023-11-30
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	1	2023-11-30
K-0324	Provide properly protected cooking facilities.	1	2023-11-30
K-0161	Use approved construction type or materials.	1	2022-06-17

What the citations cover

Citations by CMS category

Smoke Deficiencies 7
Services Deficiencies 3
Egress Deficiencies 2
Gas, Vacuum, and Electrical Systems Deficiencies 1
Other 1

Citations by CMS category
Category	Citations
Smoke Deficiencies	7
Services Deficiencies	3
Egress Deficiencies	2
Gas, Vacuum, and Electrical Systems Deficiencies	1
Construction Deficiencies	1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

April 10, 2025 — 1 citation

Citations issued on April 10, 2025
Tag	What the surveyor checks	Status
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (June 2, 2025)

November 30, 2023 — 10 citations

Citations issued on November 30, 2023
Tag	What the surveyor checks	Status
K-0222	Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.	Deficient, Provider has date of correction (February 8, 2024)
K-0291	Install emergency lighting that can last at least 1 1/2 hours.	Deficient, Provider has date of correction (February 8, 2024)
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (February 8, 2024)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (February 8, 2024)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (February 8, 2024)
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	Deficient, Provider has date of correction (February 8, 2024)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (February 8, 2024)
K-0511	Have properly installed electrical wiring and gas equipment.	Deficient, Provider has date of correction (February 8, 2024)
K-0521	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Deficient, Provider has date of correction (February 8, 2024)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (February 8, 2024)

June 17, 2022 — 3 citations

Citations issued on June 17, 2022
Tag	What the surveyor checks	Status
K-0161	Use approved construction type or materials.	Deficient, Provider has date of correction (August 28, 2022)
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (August 28, 2022)
K-0521	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Deficient, Provider has date of correction (August 28, 2022)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.