Cycle 1
Health 2025-12-11 · Fire 2024-09-11
3 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
1 fire-safety deficiencies
Top issue: Construction (1 deficiency)
North Wilkesboro, NC
Wilkesboro Health and Rehabilitation
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
204 Old Brickyard Road, North Wilkesboro, NC
(336) 667-2020
Overall
4 / 5
CMS overall stars
Health inspections
4 / 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
111
Certified beds
Average residents
100
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Sanstone Health & Rehabilitation
Operator or chain grouping
Approved since
1991-09-12
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
17 facilities
Chain averages 4 overall / 4 health / 3 staffing / 4 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
0.56
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.50
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
3.84
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
4.90
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.06
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
4.41
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.29
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
0.53
CMS adjusted RN staffing hours
Adjusted total hours
4.60
CMS adjusted total nurse staffing hours
Case-mix index
1.46
Higher values indicate more complex resident acuity
RN turnover
21%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
33%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,115
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.70
Composite VBP score used to determine payment impact.
Payment multiplier
0.9861
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 17.07% · Performance 24.15% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 7.37% · Performance 8.33% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
8.07
Baseline 38.46% · Performance 30.70% · Measure score 8.07 · Achievement 8.07 · Improvement 5.20
Adjusted total nurse staffing
4.21
Baseline 3.48 hours · Performance 4.28 hours · Measure score 4.21 · Achievement 4.21 · Improvement 2.97
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 14.75% |
10.72%
4 pts worse
|
Worse than the National Rate · Eligible stays 268 · Observed rate 17.16% · Lower 95% interval 11.22% |
| Discharge to community | 61.09% |
50.57%
10.5 pts better
|
Better than the National Rate · Eligible stays 244 · Observed rate 57.38% · Lower 95% interval 55.81% |
| Medicare spending per beneficiary | 1.23 |
1.02
0.2 pts worse
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 124 · Denominator 124 |
| Falls with major injury | 0.81% |
0.77%
About the same
|
Numerator 1 · Denominator 124 |
| Discharge self-care score | 39.8% |
53.69%
13.9 pts worse
|
Numerator 39 · Denominator 98 |
| Discharge mobility score | 41.84% |
50.94%
9.1 pts worse
|
Numerator 41 · Denominator 98 |
| Pressure ulcers or injuries, new or worsened | 3.23% |
2.29%
0.9 pts worse
|
Numerator 4 · Denominator 124 · Adjusted rate 3.08% |
| Healthcare-associated infections requiring hospitalization | 8.33% |
7.12%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 175 · Observed rate 9.14% · Lower 95% interval 5.79% |
| Staff COVID-19 vaccination coverage | 0.56% |
8.2%
7.6 pts worse
|
Numerator 1 · Denominator 180 |
| Staff flu vaccination coverage | 62.99% |
42%
21 pts better
|
Numerator 97 · Denominator 154 |
| Discharge function score | 52.04% |
56.45%
4.4 pts worse
|
Numerator 51 · Denominator 98 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 91 · Denominator 91 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 29.03% |
25.2%
3.8 pts better
|
Numerator 18 · Denominator 62 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.0 |
1.8
0.2 pts worse
|
1.9
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.0 · Observed 2.8 · Expected 2.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.5 |
1.8
0.7 pts worse
|
1.8
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 3.2 · Expected 2.1 · Used in QM five-star |
| 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 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 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 | 5.5% |
3.6%
1.9 pts worse
|
3.3%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 4.6% · Q3 5.9% · Q4 5.5% · 4Q avg 5.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 13.1% |
4.8%
8.3 pts worse
|
11.4%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.3% · Q2 12.9% · Q3 14.8% · Q4 10.6% · 4Q avg 13.1% |
| Percentage of long-stay residents who lose too much weight | 5.7% |
7.2%
1.5 pts better
|
5.4%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 6.7% · Q3 3.2% · Q4 9.1% · 4Q avg 5.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 23.8% |
21.6%
2.2 pts worse
|
19.6%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.7% · Q2 19.7% · Q3 25.8% · Q4 25.8% · 4Q avg 23.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 5.9% |
15.0%
9.1 pts better
|
16.7%
10.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.9% · Q2 6.4% · Q3 8.2% · Q4 3.6% · 4Q avg 5.9% · 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 | 34.5% |
21.5%
13 pts worse
|
16.3%
18.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.2% · Q2 37.4% · Q3 38.5% · Q4 27.6% · 4Q avg 34.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 23.5% |
16.8%
6.7 pts worse
|
14.9%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 30.0% · Q3 23.3% · Q4 23.1% · 4Q avg 23.5% · 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 · 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 | 3.7% |
2.6%
1.1 pts worse
|
1.7%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.1% · Q3 4.4% · Q4 6.8% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.4% |
21.2%
3.8 pts better
|
19.8%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.9% · Q2 16.6% · Q3 22.7% · Q4 10.1% · 4Q avg 17.4% |
| Percentage of long-stay residents with pressure ulcers | 2.8% |
6.0%
3.2 pts better
|
5.1%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 1.7% · Q3 1.3% · Q4 2.4% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
79.9%
19.5 pts better
|
81.7%
17.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.4% · Q2 99.4% · Q3 98.8% · Q4 100.0% · 4Q avg 99.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.1% |
13.2%
5.9 pts worse
|
12.0%
7.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 19.1% · Observed 16.7% · Expected 9.8% · 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 0.9% · Q2 1.0% · Q3 1.1% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.5% |
78.1%
21.4 pts better
|
79.7%
19.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.2% |
22.9%
1.3 pts worse
|
23.9%
0.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.2% · Observed 23.2% · Expected 22.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-11 · Fire 2023-06-15
6 health deficiencies
Top issue: Resident Rights (3 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-06-15 · Fire 2021-12-02
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 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
2024-09-11
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-11-06
D · Potential for more than minimal harm
2023-06-15
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-07-29
D · Potential for more than minimal harm
2023-06-15
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-07-29
D · Potential for more than minimal harm
2023-06-15
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2023-07-29
D · Potential for more than minimal harm
2021-12-02
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-02-16
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-11
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-12-30
D · Potential for more than minimal harm
2025-12-11
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-12-30
D · Potential for more than minimal harm
2025-12-11
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 2025-12-30
E · Potential for more than minimal harm
2024-09-11
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-09-12
E · Potential for more than minimal harm
2024-09-11
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 2024-09-12
D · Potential for more than minimal harm
2024-09-11
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-09-25
D · Potential for more than minimal harm
2024-09-11
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2024-09-12
D · Potential for more than minimal harm
2024-09-11
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2024-10-03
D · Potential for more than minimal harm
2024-09-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-12
E · Potential for more than minimal harm
2023-06-15
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-06-30
D · Potential for more than minimal harm
2023-06-15
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 2023-07-12
D · Potential for more than minimal harm
2023-06-15
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 2023-06-30
D · Potential for more than minimal harm
2023-06-15
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-19
D · Potential for more than minimal harm
2023-06-15
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-07-17
D · Potential for more than minimal harm
2023-06-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-12
Penalties and ownership
What sits behind the stars
Ownership
Sprenger, Christopher
5% Or Greater Direct Ownership Interest · Individual
Sprenger, Christopher
Operational/Managerial Control · Individual
Sprenger, Christopher
Corporate Officer · Individual
Wilkesboro Health And Rehabilitation LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Wilkes Regional Medical Ctr Sn
North Wilkesboro, NC
4-star overall rating with 2-star inspections with 11 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Ridge Valley Center for Nursing and Rehabilitation
Wilkesboro, NC
1-star overall rating with 1-star inspections with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Westwood Hills Nursing and Rehabilitation Center
Wilkesboro, NC
4-star overall rating with 4-star inspections with $8,648 in total fines with 2 recent health deficiencies
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