Cycle 1
Health 2025-07-24 · Fire 2024-05-10
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Burlington, NC
Edgewood Place at the Village at Brookwood
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1820 Brookwood Avenue, Burlington, NC
(336) 570-8400
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
51
Certified beds
Average residents
21
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1973-05-01
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
1.38
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
1.10
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.80
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
5.28
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
2.48
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
4.81
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
1.14
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
1.72
CMS adjusted RN staffing hours
Adjusted total hours
6.59
CMS adjusted total nurse staffing hours
Case-mix index
1.10
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
23%
Annual nurse turnover · state 50% · national 46%
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 20 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 18 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 10 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 14 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 12.66% |
8.2%
4.5 pts better
|
Numerator 10 · Denominator 79 |
| Staff flu vaccination coverage | 34.44% |
42%
7.6 pts worse
|
Numerator 31 · Denominator 90 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.5%
8.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.1%
5.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.2% |
3.6%
0.4 pts better
|
3.3%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.2% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
7.2%
7.2 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 22.9% |
21.6%
1.3 pts worse
|
19.6%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 22.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 17.5% |
15.0%
2.5 pts worse
|
16.7%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.5% · 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 · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 17.3% |
21.5%
4.2 pts better
|
16.3%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.5% |
16.8%
8.7 pts worse
|
14.9%
10.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 25.5% · 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 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.9% |
2.6%
2.3 pts worse
|
1.7%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 19.2% |
21.2%
2 pts better
|
19.8%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 19.2% |
| Percentage of long-stay residents with pressure ulcers | 0.0% |
6.0%
6 pts better
|
5.1%
5.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.3% |
79.9%
12.4 pts better
|
81.7%
10.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q3 95.2% · Q4 91.7% · 4Q avg 92.3% |
| 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 · 4Q avg 0.0% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-05-10 · Fire 2023-03-03
0 health deficiencies
No concentrated health issue counts in this cycle.
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Cycle 3
Health 2023-03-03 · Fire 2019-12-19
7 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-05-10
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-06-20
F · Potential for more than minimal harm
2023-03-03
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-03-03
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 2023-04-28
F · Potential for more than minimal harm
2019-12-19
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2020-02-28
F · Potential for more than minimal harm
2019-12-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-02-28
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-07-24
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 2025-08-15
D · Potential for more than minimal harm
2023-03-03
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 2023-03-24
D · Potential for more than minimal harm
2023-03-03
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2023-03-24
D · Potential for more than minimal harm
2023-03-03
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 2023-03-24
D · Potential for more than minimal harm
2023-03-03
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-03-24
D · Potential for more than minimal harm
2023-03-03
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 2023-03-24
D · Potential for more than minimal harm
2023-03-03
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-03-24
D · Potential for more than minimal harm
2023-03-03
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 2023-03-24
Penalties and ownership
What sits behind the stars
Ownership
Well Spring Retirement Community
5% Or Greater Direct Ownership Interest · Organization
Mayberry, April
Operational/Managerial Control · Individual
Tutterow, Alan
Corporate Officer · Individual
Nearby options
Other facilities in reach
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White Oak Manor - Burlington
Burlington, NC
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $148,522 in total fines with 9 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Liberty Commons Nursing & Rehabilitation Center of
Burlington, NC
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Alamance Health Care Center
Burlington, NC
2-star overall rating with 2-star inspections with $157,560 in total fines with 6 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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