Cycle 1
Health 2025-04-30 · Fire 2025-04-30
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
3 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Scotland Neck, NC
Bryan Health and Rehab
5-star overall rating with 5-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
921 Junior High School Road, Scotland Neck, NC
(252) 826-4144
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
60
Certified beds
Average residents
48
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1993-03-11
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
0.75
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.64
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.56
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.94
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.39
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.56
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.58
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.89
CMS adjusted RN staffing hours
Adjusted total hours
4.68
CMS adjusted total nurse staffing hours
Case-mix index
1.15
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
36%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,450
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
32.81
Composite VBP score used to determine payment impact.
Payment multiplier
0.9873
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.66
Baseline 19.91% · Performance 21.13% · Measure score 0.66 · Achievement 0.66 · Improvement 0
Healthcare-associated infections
3.01
Baseline 5.49% · Performance 6.93% · Measure score 3.01 · Achievement 3.01 · Improvement 0
Total nurse turnover
4.37
Performance 45.83% · Measure score 4.37 · Achievement 4.37 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
5.09
Baseline 4.18 hours · Performance 4.52 hours · Measure score 5.09 · Achievement 5.09 · Improvement 1.65
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.24% |
10.72%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 50 · Observed rate 14% · Lower 95% interval 7.38% |
| Discharge to community | 48.73% |
50.57%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 45 · Observed rate 42.22% · Lower 95% interval 33.63% |
| Medicare spending per beneficiary | 1.15 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 46 · Denominator 46 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 46 |
| Discharge self-care score | 50% |
53.69%
3.7 pts worse
|
Numerator 14 · Denominator 28 |
| Discharge mobility score | 39.29% |
50.94%
11.6 pts worse
|
Numerator 11 · Denominator 28 |
| Pressure ulcers or injuries, new or worsened | 6.52% |
2.29%
4.2 pts worse
|
Numerator 3 · Denominator 46 · Adjusted rate 5.84% |
| Healthcare-associated infections requiring hospitalization | 6.93% |
7.12%
0.2 pts better
|
No Different than the National Rate · Eligible stays 36 · Observed rate 5.56% · Lower 95% interval 3.26% |
| Staff COVID-19 vaccination coverage | 15.48% |
8.2%
7.3 pts better
|
Numerator 13 · Denominator 84 |
| Staff flu vaccination coverage | 31.07% |
42%
10.9 pts worse
|
Numerator 32 · Denominator 103 |
| Discharge function score | 50% |
56.45%
6.5 pts worse
|
Numerator 14 · Denominator 28 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 11.54% |
25.2%
13.7 pts worse
|
Numerator 3 · Denominator 26 |
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 1.2 · Expected 1.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.6 |
1.8
0.2 pts better
|
1.8
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.1 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 81.4% |
91.5%
10.1 pts worse
|
93.4%
12 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 80.5% · Q2 80.0% · Q3 80.0% · Q4 84.8% · 4Q avg 81.4% |
| 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 | 2.4% |
3.6%
1.2 pts better
|
3.3%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.5% · Q3 2.5% · Q4 2.2% · 4Q avg 2.4% · 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 | 5.0% |
7.2%
2.2 pts better
|
5.4%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 2.6% · Q3 5.1% · Q4 9.1% · 4Q avg 5.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 28.7% |
21.6%
7.1 pts worse
|
19.6%
9.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.3% · Q2 30.0% · Q3 22.5% · Q4 32.6% · 4Q avg 28.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 30.9% |
15.0%
15.9 pts worse
|
16.7%
14.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 37.5% · Q2 33.3% · Q3 29.4% · Q4 24.3% · 4Q avg 30.9% · 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 | 16.0% |
21.5%
5.5 pts better
|
16.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 28.9% |
16.8%
12.1 pts worse
|
14.9%
14 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.7% · Q2 22.9% · Q3 34.3% · Q4 28.6% · 4Q avg 28.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.9%
0.4 pts better
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.5% |
2.6%
0.1 pts better
|
1.7%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 0.0% · Q3 2.6% · Q4 4.5% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.0% |
21.2%
5.2 pts better
|
19.8%
3.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 22.0% · Q2 14.1% · Q3 8.3% · Q4 19.0% · 4Q avg 16.0% |
| Percentage of long-stay residents with pressure ulcers | 9.7% |
6.0%
3.7 pts worse
|
5.1%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 8.1% · Q3 10.4% · Q4 11.0% · 4Q avg 9.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 51.2% |
79.9%
28.7 pts worse
|
81.7%
30.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 36.7% · Q2 45.9% · Q3 55.3% · Q4 72.7% · 4Q avg 51.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.5% |
13.2%
1.7 pts better
|
12.0%
0.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.5% · Observed 11.4% · Expected 11.1% · 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% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 57.5% |
78.1%
20.6 pts worse
|
79.7%
22.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 57.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.3% |
22.9%
1.4 pts worse
|
23.9%
0.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.3% · Observed 27.3% · Expected 26.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-01 · Fire 2024-05-01
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-12-08 · Fire 2022-12-08
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
3 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-30
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2025-05-27
D · Potential for more than minimal harm
2025-04-30
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-06-11
D · Potential for more than minimal harm
2025-04-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-06-11
D · Potential for more than minimal harm
2024-05-01
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 2024-06-10
D · Potential for more than minimal harm
2024-05-01
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-06-10
D · Potential for more than minimal harm
2022-12-08
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-01-13
D · Potential for more than minimal harm
2022-12-08
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2023-01-13
C · Minimal harm
2022-12-08
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2023-01-13
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-04-30
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 2025-05-27
D · Potential for more than minimal harm
2025-04-30
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2025-05-27
E · Potential for more than minimal harm
2022-12-08
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 2022-12-28
E · Potential for more than minimal harm
2022-12-08
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 2022-12-28
Penalties and ownership
What sits behind the stars
Ownership
Majure, Thomas
5% Or Greater Direct Ownership Interest · Individual
Majure, Thomas
Corporate Officer · Individual
Taylor, Stephanie
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Scotland Manor Health and Rehabilitation Center
Scotland Neck, NC
4-star overall rating with 4-star inspections with $7,361 in total fines with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Rich Square Nursing & Rehabilitation Center
Rich Square, NC
1-star overall rating with 1-star inspections with $190,684 in total fines with 10 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Northampton Nursing and Rehabilitation Center
Jackson, NC
3-star overall rating with 4-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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