Cycle 1
Health 2025-03-05 · Fire 2025-03-05
17 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Bolivia, NC
Brunswick Rehabilitation and Healthcare Center
1-star overall rating with 1-star inspections with $109,733 in total fines with 17 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1070 Old Ocean Highway, Bolivia, NC
(910) 755-5955
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
90
Certified beds
Average residents
80
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Yad Healthcare
Operator or chain grouping
Approved since
2010-01-06
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
13 facilities
Chain averages 2 overall / 2 health / 2 staffing / 3 quality stars
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
0.41
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
1.25
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
1.86
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.53
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.66
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.18
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.33
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
0.45
CMS adjusted RN staffing hours
Adjusted total hours
3.84
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
88%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
72%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,962
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
25.16
Composite VBP score used to determine payment impact.
Payment multiplier
0.9837
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 16.82% · Performance 22.50% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
4.11
Baseline 7.58% · Performance 6.61% · Measure score 4.11 · Achievement 4.11 · Improvement 3.27
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
3.44
Baseline 4.07 hours · Performance 4.06 hours · Measure score 3.44 · Achievement 3.44 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.98% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 185 · Observed rate 10.81% · Lower 95% interval 7.77% |
| Discharge to community | 50.78% |
50.57%
0.2 pts better
|
No Different than the National Rate · Eligible stays 180 · Observed rate 46.67% · Lower 95% interval 44.87% |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 101 · Denominator 101 |
| Falls with major injury | 0.99% |
0.77%
0.2 pts worse
|
Numerator 1 · Denominator 101 |
| Discharge self-care score | 51.47% |
53.69%
2.2 pts worse
|
Numerator 35 · Denominator 68 |
| Discharge mobility score | 66.18% |
50.94%
15.2 pts better
|
Numerator 45 · Denominator 68 |
| Pressure ulcers or injuries, new or worsened | 5.94% |
2.29%
3.7 pts worse
|
Numerator 6 · Denominator 101 · Adjusted rate 4.45% |
| Healthcare-associated infections requiring hospitalization | 6.61% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 87 · Observed rate 4.6% · Lower 95% interval 3.59% |
| Staff COVID-19 vaccination coverage | 24.1% |
8.2%
15.9 pts better
|
Numerator 20 · Denominator 83 |
| Staff flu vaccination coverage | 16.26% |
42%
25.7 pts worse
|
Numerator 20 · Denominator 123 |
| Discharge function score | 72.06% |
56.45%
15.6 pts better
|
Numerator 49 · Denominator 68 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 35 · Denominator 35 |
| Transfer of health information to patient | 80.95% |
96.28%
15.3 pts worse
|
Numerator 34 · Denominator 42 |
| Resident COVID-19 vaccinations up to date | 3.45% |
25.2%
21.8 pts worse
|
Numerator 2 · Denominator 58 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.1 |
1.8
0.3 pts worse
|
1.9
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.1 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.0 |
1.8
0.2 pts worse
|
1.8
0.2 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 1.9 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.2% |
91.5%
6.7 pts better
|
93.4%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.0% · Q2 98.6% · Q3 98.5% · Q4 98.5% · 4Q avg 98.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.2% |
94.1%
2.1 pts better
|
95.5%
0.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.4% |
3.6%
0.8 pts worse
|
3.3%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 5.6% · Q3 4.5% · Q4 5.9% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 16.5% |
4.8%
11.7 pts worse
|
11.4%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.2% · Q2 20.3% · Q3 18.6% · Q4 19.3% · 4Q avg 16.5% |
| Percentage of long-stay residents who lose too much weight | 14.4% |
7.2%
7.2 pts worse
|
5.4%
9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 13.6% · Q2 12.7% · Q3 11.5% · Q4 20.0% · 4Q avg 14.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 28.2% |
21.6%
6.6 pts worse
|
19.6%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.2% · Q2 30.2% · Q3 28.1% · Q4 28.3% · 4Q avg 28.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.1% |
15.0%
0.1 pts worse
|
16.7%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 23.1% · Q2 7.5% · Q3 12.5% · Q4 17.6% · 4Q avg 15.1% · 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 | 30.7% |
21.5%
9.2 pts worse
|
16.3%
14.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.6% · Q2 32.0% · Q3 37.3% · 4Q avg 30.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 14.0% |
16.8%
2.8 pts better
|
14.9%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 24.1% · Q3 9.8% · Q4 13.5% · 4Q avg 14.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.9%
0.5 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
2.6%
2.2 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.8% |
21.2%
3.6 pts worse
|
19.8%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.6% · Q2 27.2% · Q3 26.0% · Q4 26.3% · 4Q avg 24.8% |
| Percentage of long-stay residents with pressure ulcers | 8.3% |
6.0%
2.3 pts worse
|
5.1%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 7.6% · Q3 7.5% · Q4 12.0% · 4Q avg 8.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.9% |
79.9%
15 pts better
|
81.7%
13.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 88.4% · Q2 98.0% · Q3 96.2% · Q4 97.9% · 4Q avg 94.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.6% |
13.2%
4.4 pts worse
|
12.0%
5.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.6% · Observed 19.4% · Expected 12.3% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.8% |
1.5%
0.7 pts better
|
1.6%
0.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.6% · Q4 1.6% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
78.1%
21.9 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.9% |
22.9%
About the same
|
23.9%
1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.9% · Observed 25.8% · Expected 26.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-27 · Fire 2024-03-27
6 health deficiencies
Top issue: Nursing and Physician Services (2 deficiencies)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Cycle 3
Health 2022-12-16 · Fire 2022-12-16
12 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-03-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-18
F · Potential for more than minimal harm
2024-09-05
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2024-09-12
D · Potential for more than minimal harm
2024-09-05
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-09-12
D · Potential for more than minimal harm
2024-09-05
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 2024-09-12
F · Potential for more than minimal harm
2024-03-27
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-05-23
D · Potential for more than minimal harm
2024-03-27
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-05-23
F · Potential for more than minimal harm
2022-12-16
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-03-01
F · Potential for more than minimal harm
2022-12-16
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2023-03-01
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-03-05
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 2025-04-04
E · Potential for more than minimal harm
2025-03-05
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 2025-04-04
E · Potential for more than minimal harm
2025-03-05
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-04-04
E · Potential for more than minimal harm
2025-03-05
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-04-04
E · Potential for more than minimal harm
2025-03-05
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2025-04-04
E · Potential for more than minimal harm
2025-03-05
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 2025-04-04
E · Potential for more than minimal harm
2025-03-05
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-04-04
E · Potential for more than minimal harm
2025-03-05
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 2025-04-04
E · Potential for more than minimal harm
2025-03-05
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2025-04-04
E · Potential for more than minimal harm
2025-03-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-03-05
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-03-05
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-03-05
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-03-05
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-03-05
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-03-05
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2025-04-04
B · Minimal harm
2025-03-05
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-04-04
F · Potential for more than minimal harm
2024-03-27
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-04-24
E · Potential for more than minimal harm
2024-03-27
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-04-24
E · Potential for more than minimal harm
2024-03-27
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 2024-04-24
E · Potential for more than minimal harm
2024-03-27
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-04-24
D · Potential for more than minimal harm
2024-03-27
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-04-24
C · Minimal harm
2024-03-27
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-04-24
E · Potential for more than minimal harm
2024-01-25
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-02-15
E · Potential for more than minimal harm
2024-01-25
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-02-15
D · Potential for more than minimal harm
2024-01-25
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-02-15
J · Immediate jeopardy
2023-12-11
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2024-01-25
J · Immediate jeopardy
2023-12-11
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-01-25
E · Potential for more than minimal harm
2023-12-11
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-02-15
J · Immediate jeopardy
2023-06-02
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 2023-05-11
F · Potential for more than minimal harm
2022-12-16
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2023-03-01
E · Potential for more than minimal harm
2022-12-16
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-02-04
E · Potential for more than minimal harm
2022-12-16
F914 · Environmental Deficiencies
Health
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Corrected 2023-02-04
D · Potential for more than minimal harm
2022-12-16
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-02-04
D · Potential for more than minimal harm
2022-12-16
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-03-01
Penalties and ownership
What sits behind the stars
$94,140
2023-12-11
Fine
Fine · fine $94,140
Fine
$0
2023-12-11
Payment Denial
Payment Denial · denial start 2024-01-12 · 34 days
34 day denial
$15,593
2023-06-02
Fine
Fine · fine $15,593
Fine
Ownership
Brunswick Holdings I LLC
5% Or Greater Direct Ownership Interest · Organization
Alter, Tzvi
5% Or Greater Indirect Ownership Interest · Individual
Lellock, Ty
Operational/Managerial Control · Individual
West Nc Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Autumn Care of Shallotte
Shallotte, NC
3-star overall rating with 3-star inspections with $51,348 in total fines with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Liberty Commons Nursing & Rehab Center of Southpor
Southport, NC
3-star overall rating with 3-star inspections with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Brunswick Health & Rehab Center
Ash, NC
1-star overall rating with 1-star inspections with $186,707 in total fines with 12 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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