Cycle 1
Health 2025-08-01 · Fire 2024-05-09
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Winston-Salem, NC
Brookridge Retirement Community
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
1199 Hayes Forest Drive, Winston-Salem, NC
(336) 759-1044
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
77
Certified beds
Average residents
57
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1981-06-01
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
0.72
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
1.30
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
3.76
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
5.77
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
2.01
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
5.08
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.51
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.76
CMS adjusted RN staffing hours
Adjusted total hours
6.11
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
64%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
57%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,176
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.56
Composite VBP score used to determine payment impact.
Payment multiplier
0.9835
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.19
Baseline 19.18% · Performance 20.42% · Measure score 2.19 · Achievement 2.19 · Improvement 0
Healthcare-associated infections
4.83
Baseline 5.50% · Performance 6.39% · Measure score 4.83 · Achievement 4.83 · Improvement 0
Total nurse turnover
0
Baseline 64.00% · Performance 76.29% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
2.80
Baseline 6.10 hours · Performance 3.87 hours · Measure score 2.80 · Achievement 2.80 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.58% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 148 · Observed rate 9.46% · Lower 95% interval 7.87% |
| Discharge to community | 72.28% |
50.57%
21.7 pts better
|
Better than the National Rate · Eligible stays 145 · Observed rate 69.66% · Lower 95% interval 65% |
| Medicare spending per beneficiary | 0.98 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 72.38% |
95.27%
22.9 pts worse
|
Numerator 76 · Denominator 105 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 105 |
| Discharge self-care score | 61.25% |
53.69%
7.6 pts better
|
Numerator 49 · Denominator 80 |
| Discharge mobility score | 55% |
50.94%
4.1 pts better
|
Numerator 44 · Denominator 80 |
| Pressure ulcers or injuries, new or worsened | 1.9% |
2.29%
0.4 pts better
|
Numerator 2 · Denominator 105 · Adjusted rate 1.89% |
| Healthcare-associated infections requiring hospitalization | 6.39% |
7.12%
0.7 pts better
|
No Different than the National Rate · Eligible stays 93 · Observed rate 4.3% · Lower 95% interval 3.67% |
| Staff COVID-19 vaccination coverage | 1.69% |
8.2%
6.5 pts worse
|
Numerator 4 · Denominator 237 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 63.75% |
56.45%
7.3 pts better
|
Numerator 51 · Denominator 80 |
| Transfer of health information to provider | 76.79% |
95.95%
19.2 pts worse
|
Numerator 43 · Denominator 56 |
| Transfer of health information to patient | 83.87% |
96.28%
12.4 pts worse
|
Numerator 26 · Denominator 31 |
| Resident COVID-19 vaccinations up to date | 24.59% |
25.2%
0.6 pts worse
|
Numerator 15 · Denominator 61 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
91.5%
7.8 pts better
|
93.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 97.5% · Q4 100.0% · 4Q avg 99.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 86.7% |
94.1%
7.4 pts worse
|
95.5%
8.8 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 86.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.7% |
3.6%
2.9 pts better
|
3.3%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.6% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.5% |
4.8%
2.3 pts better
|
11.4%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.5% · Q3 2.8% · Q4 2.8% · 4Q avg 2.5% |
| Percentage of long-stay residents who lose too much weight | 7.4% |
7.2%
0.2 pts worse
|
5.4%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 11.5% · Q3 11.4% · Q4 0.0% · 4Q avg 7.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.7% |
21.6%
7.9 pts better
|
19.6%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 14.8% · Q3 16.7% · Q4 8.6% · 4Q avg 13.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.9% |
15.0%
6.1 pts better
|
16.7%
7.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 4.5% · Q3 10.7% · Q4 11.1% · 4Q avg 8.9% · 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 | 3.6% |
21.5%
17.9 pts better
|
16.3%
12.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 4.4% |
16.8%
12.4 pts better
|
14.9%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 12.0% · Q3 3.1% · Q4 3.1% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
2.6%
2.6 pts better
|
1.7%
1.7 pts better
|
Long 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 long-stay residents with new or worsened bowel or bladder incontinence | 9.9% |
21.2%
11.3 pts better
|
19.8%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 10.1% · Q3 6.2% · Q4 12.4% · 4Q avg 9.9% |
| Percentage of long-stay residents with pressure ulcers | 7.9% |
6.0%
1.9 pts worse
|
5.1%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 10.2% · Q3 9.6% · Q4 6.8% · 4Q avg 7.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.0% |
79.9%
13.1 pts better
|
81.7%
11.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.7% · Q2 90.7% · Q3 88.8% · Q4 93.5% · 4Q avg 93.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.6% |
13.2%
5.6 pts better
|
12.0%
4.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.6% · Observed 7.3% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.5%
0.4 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 2.2% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.0% |
78.1%
6.9 pts better
|
79.7%
5.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.5% |
22.9%
0.6 pts worse
|
23.9%
0.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.5% · Observed 22.9% · Expected 23.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-09 · Fire 2023-01-26
2 health deficiencies
Top issue: Nutrition and Dietary (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-01-26 · Fire 2021-08-05
2 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-05-09
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 2024-09-01
F · Potential for more than minimal harm
2024-05-09
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 2024-09-01
F · Potential for more than minimal harm
2024-05-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-01
E · Potential for more than minimal harm
2024-05-09
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-09-01
E · Potential for more than minimal harm
2024-05-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-09-01
E · Potential for more than minimal harm
2024-05-09
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-09-01
D · Potential for more than minimal harm
2024-05-09
K281 · Egress Deficiencies
Fire Safety
Install proper backup exit lighting.
Corrected 2024-09-01
D · Potential for more than minimal harm
2024-05-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-09-01
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-01
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-09-08
F · Potential for more than minimal harm
2024-05-09
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 2024-06-20
F · Potential for more than minimal harm
2024-05-09
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2024-06-27
D · Potential for more than minimal harm
2023-01-26
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-03-13
B · Minimal harm
2023-01-26
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 2023-03-13
Penalties and ownership
What sits behind the stars
Ownership
Baptist Retirement Homes Of North Carolina Incorporated
5% Or Greater Direct Ownership Interest · Organization
Baptist Retirement Homes Of North Carolina Incorporated
Operational/Managerial Control · Organization
Nathan, Jessica
Operational/Managerial Control · Individual
Vanderslik, Reed
Operational/Managerial Control · Individual
Vanderslik, Reed
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Mill Creek Center for Nursing and Rehabilitation
Winston-Salem, NC
1-star overall rating with 1-star inspections with $29,876 in total fines with 14 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Salemtowne
Winston-Salem, NC
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Arbor Acres United Methodist Retirement Community
Winston Salem, NC
4-star overall rating with 5-star inspections with 2 fire-safety deficiencies in the latest cycle
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