Yadkinville, NC

Willowbrook Rehabilitation and Care

4-star overall rating with 4-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

333 East Lee Street, Yadkinville, NC

(336) 679-8028

Compare this facility

Overall

4 / 5

CMS overall stars

Health inspections

4 / 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

76

Certified beds

Average residents

69

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Consulate Health Care/Independence Living Centers/Nspire Healthcare/Raydiant Health Care

Operator or chain grouping

Approved since

1994-10-31

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

36 facilities

Chain averages 2 overall / 2 health / 3 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

0.36

Registered nurse staffing · state 0.59 · national 0.68

LPN hours / resident day

0.77

Licensed practical nurse staffing · state 0.87 · national 0.87

Aide hours / resident day

1.99

Nurse aide staffing · state 2.33 · national 2.35

Total nurse hours

3.13

All reported nurse hours · state 3.78 · national 3.89

Licensed hours

1.13

RN + LPN hours · state 1.45 · national 1.54

Weekend hours

2.85

Weekend nurse staffing · state 3.34 · national 3.43

Weekend RN hours

0.21

Weekend registered nurse coverage · state 0.38 · national 0.47

Physical therapist

0.01

Reported PT staffing · state 0.09 · national 0.07

Adjusted RN hours

0.41

CMS adjusted RN staffing hours

Adjusted total hours

3.54

CMS adjusted total nurse staffing hours

Case-mix index

1.21

Higher values indicate more complex resident acuity

RN turnover

50%

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

1,401

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

56.96

Composite VBP score used to determine payment impact.

Payment multiplier

1.0121

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

6.56

Baseline 9.03% · Performance 6.18% · Measure score 6.56 · Achievement 5.53 · Improvement 6.56

Total nurse turnover

9.09

Baseline 36.84% · Performance 26.53% · Measure score 9.09 · Achievement 9.09 · Improvement 8.10

Adjusted total nurse staffing

1.44

Baseline 3.44 hours · Performance 3.49 hours · Measure score 1.44 · Achievement 1.44 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	11.33%	10.72% 0.6 pts worse	No Different than the National Rate · Eligible stays 51 · Observed rate 15.69% · Lower 95% interval 7.94%
Discharge to community	35.43%	50.57% 15.1 pts worse	No Different than the National Rate · Eligible stays 44 · Observed rate 22.73% · Lower 95% interval 23.77%
Medicare spending per beneficiary	0.84	1.02 0.2 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 36 · Denominator 36
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 36
Discharge self-care score	81.82%	53.69% 28.1 pts better	Numerator 18 · Denominator 22
Discharge mobility score	50%	50.94% 0.9 pts worse	Numerator 11 · Denominator 22
Pressure ulcers or injuries, new or worsened	8.33%	2.29% 6 pts worse	Numerator 3 · Denominator 36 · Adjusted rate 9.88%
Healthcare-associated infections requiring hospitalization	6.18%	7.12% 0.9 pts better	No Different than the National Rate · Eligible stays 25 · Observed rate 0% · Lower 95% interval 2.64%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 48
Staff flu vaccination coverage	14.49%	42% 27.5 pts worse	Numerator 10 · Denominator 69
Discharge function score	72.73%	56.45% 16.3 pts better	Numerator 16 · Denominator 22
Transfer of health information to provider	100%	95.95% 4 pts better	Numerator 20 · Denominator 20
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	4.76%	25.2% 20.4 pts worse	Numerator 1 · Denominator 21

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	99.6%	91.5% 8.1 pts better	93.4% 6.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 98.2% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6%
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	7.9%	3.6% 4.3 pts worse	3.3% 4.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 6.8% · Q3 5.2% · Q4 10.7% · 4Q avg 7.9% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.5%	4.8% 4.3 pts better	11.4% 10.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.2% · 4Q avg 0.5%
Percentage of long-stay residents who lose too much weight	11.8%	7.2% 4.6 pts worse	5.4% 6.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 9.4% · Q3 11.1% · Q4 15.4% · 4Q avg 11.8%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	31.1%	21.6% 9.5 pts worse	19.6% 11.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 30.2% · Q2 32.7% · Q3 30.4% · Q4 30.9% · 4Q avg 31.1%
Percentage of long-stay residents who received an antipsychotic medication	26.7%	15.0% 11.7 pts worse	16.7% 10 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 29.8% · Q3 24.0% · Q4 28.6% · 4Q avg 26.7% · 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	14.3%	21.5% 7.2 pts better	16.3% 2 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 14.3% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	16.9%	16.8% 0.1 pts worse	14.9% 2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 30.4% · Q2 15.7% · Q3 6.1% · Q4 16.3% · 4Q avg 16.9% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.7%	0.9% 0.2 pts better	1.0% 0.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.4% · Q4 1.4% · 4Q avg 0.7% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	1.8%	2.6% 0.8 pts better	1.7% 0.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 3.6% · Q3 1.8% · Q4 0.0% · 4Q avg 1.8% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	27.2%	21.2% 6 pts worse	19.8% 7.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 22.3% · Q2 33.2% · Q3 24.8% · Q4 28.4% · 4Q avg 27.2%
Percentage of long-stay residents with pressure ulcers	9.3%	6.0% 3.3 pts worse	5.1% 4.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 12.8% · Q3 7.3% · Q4 7.5% · 4Q avg 9.3% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	97.8%	79.9% 17.9 pts better	81.7% 16.1 pts better	Short Stay · 2024Q4-2025Q3 · Q1 97.4% · Q2 97.4% · Q3 99.1% · Q4 97.5% · 4Q avg 97.8%
Percentage of short-stay residents who had an outpatient emergency department visit	2.7%	13.2% 10.5 pts better	12.0% 9.3 pts better	Short Stay · 20240701-20250630 · Adjusted 2.7% · Observed 2.6% · Expected 10.7% · 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 1.7% · 4Q avg 0.8% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	97.5%	78.1% 19.4 pts better	79.7% 17.8 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 97.5%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	21.0%	22.9% 1.9 pts better	23.9% 2.9 pts better	Short Stay · 20240701-20250630 · Adjusted 21.0% · Observed 21.1% · Expected 23.9% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-09-12 · Fire 2024-07-24

2 health deficiencies

Top issue: Pharmacy Service (1 deficiency)

2 fire-safety deficiencies

Top issue: Construction (1 deficiency)

Cycle 2 Health 2024-07-24 · Fire 2023-08-02

0 health deficiencies

No concentrated health issue counts in this cycle.

2 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 3 Health 2023-08-02 · Fire 2022-03-17

4 health deficiencies

Top issue: Resident Rights (2 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Fire safety

Fire-safety citations

D · Potential for more than minimal harm 2024-07-24

K161 · Construction Deficiencies

Fire Safety

Use approved construction type or materials.

Corrected 2024-09-20

D · Potential for more than minimal harm 2024-07-24

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 2024-09-20

D · Potential for more than minimal harm 2023-08-02

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-10-11

D · Potential for more than minimal harm 2023-08-02

K911 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Meet requirements for the installation and maintenance of electrical systems.

Corrected 2023-10-11

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-09-12

F658 · Resident Assessment and Care Planning Deficiencies

Health

Ensure services provided by the nursing facility meet professional standards of quality.

Corrected 2024-09-20

D · Potential for more than minimal harm 2025-09-12

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2025-09-25

D · Potential for more than minimal harm 2023-08-02

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 2023-08-22

D · Potential for more than minimal harm 2023-08-02

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 2023-08-22

B · Minimal harm 2023-08-02

F623 · Resident Rights Deficiencies

Health

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Corrected 2023-08-22

B · Minimal harm 2023-08-02

F625 · Resident Rights Deficiencies

Health

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Corrected 2023-08-22

Penalties and ownership