Cycle 1
Health 2024-12-18 · Fire 2024-12-18
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Oxford, NC
Brantwood Nh & Retirement Center
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
1038 College Street, Oxford, NC
(919) 690-3334
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
80
Certified beds
Average residents
66
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1992-01-31
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
Staffing
Hours and turnover
RN hours / resident day
0.44
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.84
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
1.70
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
2.99
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.29
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
2.60
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.21
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.00
Reported PT staffing
Adjusted RN hours
0.45
CMS adjusted RN staffing hours
Adjusted total hours
3.01
CMS adjusted total nurse staffing hours
Case-mix index
1.36
Higher values indicate more complex resident acuity
RN turnover
22%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,773
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
10.58
Composite VBP score used to determine payment impact.
Payment multiplier
0.9809
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.36% · Performance 22.73% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.15
Baseline 5.83% · Performance 6.89% · Measure score 3.15 · Achievement 3.15 · Improvement 0
Total nurse turnover
1.08
Performance 59.26% · Measure score 1.08 · Achievement 1.08 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0
Baseline 3.16 hours · Performance 3.16 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.56% |
10.72%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 84 · Observed rate 11.9% · Lower 95% interval 7.99% |
| Discharge to community | 45.69% |
50.57%
4.9 pts worse
|
No Different than the National Rate · Eligible stays 67 · Observed rate 41.79% · Lower 95% interval 36.89% |
| Medicare spending per beneficiary | 0.88 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 0% |
95.27%
95.3 pts worse
|
Numerator 0 · Denominator 55 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 55 |
| Discharge self-care score | 48.65% |
53.69%
5 pts worse
|
Numerator 18 · Denominator 37 |
| Discharge mobility score | 54.05% |
50.94%
3.1 pts better
|
Numerator 20 · Denominator 37 |
| Pressure ulcers or injuries, new or worsened | 3.64% |
2.29%
1.4 pts worse
|
Numerator 2 · Denominator 55 · Adjusted rate 3.22% |
| Healthcare-associated infections requiring hospitalization | 6.89% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 52 · Observed rate 5.77% · Lower 95% interval 3.75% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 40 |
| Staff flu vaccination coverage | 92.54% |
42%
50.5 pts better
|
Numerator 62 · Denominator 67 |
| Discharge function score | 54.05% |
56.45%
2.4 pts worse
|
Numerator 20 · Denominator 37 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 96% |
96.28%
0.3 pts worse
|
Numerator 24 · Denominator 25 |
| Resident COVID-19 vaccinations up to date | 9.09% |
25.2%
16.1 pts worse
|
Numerator 2 · Denominator 22 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.0 |
1.8
0.8 pts better
|
1.9
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 0.9 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.4 |
1.8
1.6 pts worse
|
1.8
1.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.4 · Observed 3.2 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 64.7% |
91.5%
26.8 pts worse
|
93.4%
28.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 54.9% · Q2 56.9% · Q3 65.5% · Q4 79.3% · 4Q avg 64.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.6% |
94.1%
0.5 pts better
|
95.5%
0.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.0% |
3.6%
1.4 pts worse
|
3.3%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 5.9% · Q3 5.2% · Q4 3.4% · 4Q avg 5.0% · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 4.2% |
7.2%
3 pts better
|
5.4%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 0.0% · Q3 7.7% · Q4 6.0% · 4Q avg 4.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.7% |
21.6%
13.9 pts better
|
19.6%
11.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 8.7% · Q3 7.7% · Q4 9.8% · 4Q avg 7.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.8% |
15.0%
4.8 pts worse
|
16.7%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 23.8% · Q3 19.6% · Q4 21.4% · 4Q avg 19.8% · 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 | 26.5% |
21.5%
5 pts worse
|
16.3%
10.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 26.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.8% |
16.8%
About the same
|
14.9%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 20.0% · Q3 21.4% · Q4 12.5% · 4Q avg 16.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
0.9%
0.1 pts worse
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 2.1% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.3% |
2.6%
0.7 pts worse
|
1.7%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.0% · Q3 8.6% · Q4 1.8% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.6% |
21.2%
1.6 pts better
|
19.8%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 22.7% · Q3 27.7% · Q4 12.9% · 4Q avg 19.6% |
| Percentage of long-stay residents with pressure ulcers | 6.6% |
6.0%
0.6 pts worse
|
5.1%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q2 8.2% · Q3 8.4% · Q4 4.3% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 87.7% |
79.9%
7.8 pts better
|
81.7%
6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.1% · Q2 83.7% · Q3 88.4% · Q4 89.0% · 4Q avg 87.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 29.9% |
13.2%
16.7 pts worse
|
12.0%
17.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.9% · Observed 26.4% · Expected 9.9% · 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 | 79.6% |
78.1%
1.5 pts better
|
79.7%
0.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 79.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.2% |
22.9%
5.3 pts worse
|
23.9%
4.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.2% · Observed 22.6% · Expected 19.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-09 · Fire 2023-11-09
5 health deficiencies
Top issue: Resident Rights (4 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2022-09-01 · Fire 2022-09-01
3 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
3 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-12-18
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2025-02-28
D · Potential for more than minimal harm
2024-12-18
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-02-28
D · Potential for more than minimal harm
2024-12-18
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2025-02-28
D · Potential for more than minimal harm
2024-12-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-02-28
D · Potential for more than minimal harm
2024-12-18
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-02-28
F · Potential for more than minimal harm
2023-11-09
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 2024-01-15
F · Potential for more than minimal harm
2023-11-09
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2024-01-15
F · Potential for more than minimal harm
2023-11-09
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-01-15
D · Potential for more than minimal harm
2023-11-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-01-15
D · Potential for more than minimal harm
2023-11-09
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-01-15
D · Potential for more than minimal harm
2023-11-09
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-01-15
D · Potential for more than minimal harm
2023-11-09
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-01-15
D · Potential for more than minimal harm
2022-09-01
K111 · Construction Deficiencies
Fire Safety
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Corrected 2022-10-03
D · Potential for more than minimal harm
2022-09-01
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-10-03
D · Potential for more than minimal harm
2022-09-01
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-10-03
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-12-18
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 2025-01-09
D · Potential for more than minimal harm
2024-12-18
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 2025-01-09
D · Potential for more than minimal harm
2023-11-09
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2023-12-07
D · Potential for more than minimal harm
2023-11-09
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2023-12-07
B · Minimal harm
2023-11-09
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 2023-12-07
B · Minimal harm
2023-11-09
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 2023-12-07
B · Minimal harm
2023-11-09
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-12-07
D · Potential for more than minimal harm
2022-09-01
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2022-09-15
B · Minimal harm
2022-09-01
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 2022-09-16
B · Minimal harm
2022-09-01
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2022-09-15
Penalties and ownership
What sits behind the stars
Ownership
County Of Granville
5% Or Greater Direct Ownership Interest · Organization
Cozart, Tony
Corporate Director · Individual
Gooch, James
Corporate Director · Individual
Hodge, Shane
Corporate Director · Individual
Jay, Zelodis
Corporate Director · Individual
Lumpkins, James
Corporate Director · Individual
Mcconnell, Adam
Operational/Managerial Control · Individual
Mcconnell, Adam
Corporate Director · Individual
Mcconnell, Adam
Corporate Officer · Individual
Omokunde, Dawn Marie
Corporate Director · Individual
Purvis, Jamie
Operational/Managerial Control · Individual
Purvis, Jamie
Corporate Director · Individual
Smith, David
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Oxford Health and Rehabilitation Center
Oxford, NC
2-star overall rating with 3-star inspections with 8 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Senior Citizens Home
Henderson, NC
2-star overall rating with 2-star inspections with $55,760 in total fines with 6 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
Kerr Lake Nursing and Rehabilitation Center
Henderson, NC
3-star overall rating with 3-star inspections with $32,269 in total fines with 2 recent health deficiencies
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