Cycle 1
Health 2025-12-04 · Fire 2024-07-25
6 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Winnabow, NC
Brunswick Cove Nursing Center
3-star overall rating with 3-star inspections with $107,024 in total fines with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
1478 River Road, Winnabow, NC
(910) 371-9894
Overall
3 / 5
CMS overall stars
Health inspections
3 / 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
175
Certified beds
Average residents
122
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1990-05-10
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
0.55
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.95
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.71
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
4.21
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.50
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.90
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.43
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.60
CMS adjusted RN staffing hours
Adjusted total hours
4.60
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
1,942
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
52.85
Composite VBP score used to determine payment impact.
Payment multiplier
1.0075
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.98
Baseline 18.82% · Performance 18.66% · Measure score 5.98 · Achievement 5.98 · Improvement 0.39
Healthcare-associated infections
8.12
Baseline 5.68% · Performance 5.41% · Measure score 8.12 · Achievement 8.12 · Improvement 3.50
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
1.76
Baseline 2.45 hours · Performance 3.20 hours · Measure score 1.76 · Achievement 0 · Improvement 1.76
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.2% |
10.72%
1.5 pts better
|
No Different than the National Rate · Eligible stays 126 · Observed rate 7.14% · Lower 95% interval 5.77% |
| Discharge to community | 46.66% |
50.57%
3.9 pts worse
|
No Different than the National Rate · Eligible stays 114 · Observed rate 40.35% · Lower 95% interval 39.62% |
| Medicare spending per beneficiary | 0.81 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 96.63% |
95.27%
1.4 pts better
|
Numerator 86 · Denominator 89 |
| Falls with major injury | 4.49% |
0.77%
3.7 pts worse
|
Numerator 4 · Denominator 89 |
| Discharge self-care score | 46.15% |
53.69%
7.5 pts worse
|
Numerator 30 · Denominator 65 |
| Discharge mobility score | 55.38% |
50.94%
4.4 pts better
|
Numerator 36 · Denominator 65 |
| Pressure ulcers or injuries, new or worsened | 1.12% |
2.29%
1.2 pts better
|
Numerator 1 · Denominator 89 · Adjusted rate 1.29% |
| Healthcare-associated infections requiring hospitalization | 5.41% |
7.12%
1.7 pts better
|
No Different than the National Rate · Eligible stays 77 · Observed rate 1.3% · Lower 95% interval 3.05% |
| Staff COVID-19 vaccination coverage | Not Available |
8.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 60% |
56.45%
3.5 pts better
|
Numerator 39 · Denominator 65 |
| Transfer of health information to provider | 97.3% |
95.95%
1.3 pts better
|
Numerator 36 · Denominator 37 |
| Transfer of health information to patient | 96.15% |
96.28%
0.1 pts worse
|
Numerator 25 · Denominator 26 |
| Resident COVID-19 vaccinations up to date | 34% |
25.2%
8.8 pts better
|
Numerator 17 · Denominator 50 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.9 |
1.8
0.1 pts worse
|
1.9
About the same
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.7 · Expected 1.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.7 |
1.8
0.9 pts worse
|
1.8
0.9 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.6 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.9% |
91.5%
5.4 pts better
|
93.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.2% · Q2 94.7% · Q3 96.4% · Q4 98.1% · 4Q avg 96.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.6% |
94.1%
3.5 pts better
|
95.5%
2.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.7% |
3.6%
3.1 pts worse
|
3.3%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 8.8% · Q3 5.4% · Q4 3.7% · 4Q avg 6.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 10.8% |
4.8%
6 pts worse
|
11.4%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.3% · Q2 8.0% · Q3 11.3% · Q4 13.7% · 4Q avg 10.8% |
| Percentage of long-stay residents who lose too much weight | 12.5% |
7.2%
5.3 pts worse
|
5.4%
7.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 14.1% · Q3 13.9% · Q4 10.4% · 4Q avg 12.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 24.0% |
21.6%
2.4 pts worse
|
19.6%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.0% · Q2 24.3% · Q3 22.9% · Q4 23.1% · 4Q avg 24.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.0% |
15.0%
9 pts worse
|
16.7%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 21.8% · Q3 23.3% · Q4 25.0% · 4Q avg 24.0% · 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 | 37.5% |
21.5%
16 pts worse
|
16.3%
21.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 42.1% · Q2 39.6% · 4Q avg 37.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.0% |
16.8%
8.2 pts worse
|
14.9%
10.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.1% · Q2 20.7% · Q3 24.7% · Q4 31.2% · 4Q avg 25.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
0.9%
0.3 pts worse
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.1% · Q3 0.6% · Q4 1.6% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.7% |
2.6%
0.1 pts worse
|
1.7%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 2.6% · Q3 5.4% · Q4 1.9% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.7% |
21.2%
1.5 pts worse
|
19.8%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.8% · Q2 18.0% · Q3 17.4% · Q4 32.3% · 4Q avg 22.7% |
| Percentage of long-stay residents with pressure ulcers | 5.2% |
6.0%
0.8 pts better
|
5.1%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 4.4% · Q3 4.2% · Q4 6.8% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 83.6% |
79.9%
3.7 pts better
|
81.7%
1.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 81.9% · Q2 79.0% · Q3 79.0% · Q4 94.3% · 4Q avg 83.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.1% |
13.2%
2.9 pts worse
|
12.0%
4.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.1% · Observed 17.0% · Expected 11.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.6% |
1.5%
1.1 pts worse
|
1.6%
1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 0.0% · Q3 3.4% · Q4 4.4% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 82.1% |
78.1%
4 pts better
|
79.7%
2.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 82.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.3% |
22.9%
4.6 pts better
|
23.9%
5.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.3% · Observed 19.1% · Expected 25.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-25 · Fire 2023-05-25
8 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-05-25 · Fire 2022-02-10
6 health deficiencies
Top issue: Administration (2 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-07-25
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-04
D · Potential for more than minimal harm
2024-07-25
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 2024-09-04
D · Potential for more than minimal harm
2024-07-25
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-09-04
D · Potential for more than minimal harm
2023-05-25
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-08-11
D · Potential for more than minimal harm
2023-05-25
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-11
D · Potential for more than minimal harm
2023-05-25
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-08-11
F · Potential for more than minimal harm
2022-02-10
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2022-05-20
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-04
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-12-27
D · Potential for more than minimal harm
2025-12-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-12-27
D · Potential for more than minimal harm
2025-12-04
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-12-27
D · Potential for more than minimal harm
2025-12-04
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 2025-12-27
D · Potential for more than minimal harm
2025-12-04
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-12-27
D · Potential for more than minimal harm
2025-12-04
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-12-27
E · Potential for more than minimal harm
2024-07-25
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-09-01
E · Potential for more than minimal harm
2024-07-25
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-09-01
E · Potential for more than minimal harm
2024-07-25
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-09-01
E · Potential for more than minimal harm
2024-07-25
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-09-01
D · Potential for more than minimal harm
2024-07-25
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 2024-09-01
D · Potential for more than minimal harm
2024-07-25
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-09-01
D · Potential for more than minimal harm
2024-07-25
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 2024-09-01
D · Potential for more than minimal harm
2024-07-25
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-09-01
D · Potential for more than minimal harm
2023-07-06
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 2023-07-10
E · Potential for more than minimal harm
2023-05-25
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 2023-07-06
E · Potential for more than minimal harm
2023-05-25
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-07-06
D · Potential for more than minimal harm
2023-05-25
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-07-06
D · Potential for more than minimal harm
2023-05-25
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 2023-07-06
B · Minimal harm
2023-05-25
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2023-06-01
Penalties and ownership
What sits behind the stars
$4,938
2024-02-20
Fine
Fine · fine $4,938
Fine
$4,938
2024-02-12
Fine
Fine · fine $4,938
Fine
$14,814
2024-01-22
Fine
Fine · fine $14,814
Fine
$4,938
2024-01-08
Fine
Fine · fine $4,938
Fine
$4,587
2024-01-02
Fine
Fine · fine $4,587
Fine
$13,762
2023-12-11
Fine
Fine · fine $13,762
Fine
$4,587
2023-11-06
Fine
Fine · fine $4,587
Fine
$4,587
2023-10-30
Fine
Fine · fine $4,587
Fine
$13,762
2023-10-10
Fine
Fine · fine $13,762
Fine
$4,008
2023-05-25
Fine
Fine · fine $4,008
Fine
$4,587
2023-05-23
Fine
Fine · fine $4,587
Fine
$4,587
2023-05-15
Fine
Fine · fine $4,587
Fine
$4,587
2023-05-08
Fine
Fine · fine $4,587
Fine
$13,762
2023-04-17
Fine
Fine · fine $13,762
Fine
$4,580
2023-03-20
Fine
Fine · fine $4,580
Fine
Ownership
Campbell, Hugh
5% Or Greater Direct Ownership Interest · Individual
Miller, Zachary
5% Or Greater Direct Ownership Interest · Individual
Campbell, Hugh
Operational/Managerial Control · Individual
Miller, Zachary
Operational/Managerial Control · Individual
Nearby options
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#2
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#3
Azalea Health & Rehab Center
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2-star overall rating with 2-star inspections with $24,470 in total fines with 3 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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