Cycle 1
Health 2025-11-17 · Fire 2024-07-24
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Hampstead, NC
Woodbury Wellness Center Inc
3-star overall rating with 3-star inspections with $15,646 in total fines with 1 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
2778 Country Club Drive, Hampstead, NC
(910) 270-1443
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
112
Certified beds
Average residents
104
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1990-11-07
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
0.77
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
1.15
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.74
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
4.66
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.92
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
4.09
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.41
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.80
CMS adjusted RN staffing hours
Adjusted total hours
4.82
CMS adjusted total nurse staffing hours
Case-mix index
1.32
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
1,893
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
53.20
Composite VBP score used to determine payment impact.
Payment multiplier
1.0079
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.11
Baseline 16.97% · Performance 20.91% · Measure score 1.11 · Achievement 1.11 · Improvement 0
Healthcare-associated infections
10
Baseline 5.75% · Performance 4.86% · Measure score 10 · Achievement 10 · Improvement 9
Total nurse turnover
3.78
Baseline 67.44% · Performance 49.19% · Measure score 3.78 · Achievement 3.54 · Improvement 3.78
Adjusted total nurse staffing
6.38
Baseline 4.39 hours · Performance 4.89 hours · Measure score 6.38 · Achievement 6.38 · Improvement 3.12
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.7% |
10.72%
1 pts worse
|
No Different than the National Rate · Eligible stays 346 · Observed rate 11.56% · Lower 95% interval 9.16% |
| Discharge to community | 56.37% |
50.57%
5.8 pts better
|
No Different than the National Rate · Eligible stays 322 · Observed rate 52.48% · Lower 95% interval 50.01% |
| Medicare spending per beneficiary | 0.79 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 193 · Denominator 193 |
| Falls with major injury | 1.55% |
0.77%
0.8 pts worse
|
Numerator 3 · Denominator 193 |
| Discharge self-care score | 52.38% |
53.69%
1.3 pts worse
|
Numerator 66 · Denominator 126 |
| Discharge mobility score | 54.76% |
50.94%
3.8 pts better
|
Numerator 69 · Denominator 126 |
| Pressure ulcers or injuries, new or worsened | 5.76% |
2.29%
3.5 pts worse
|
Numerator 11 · Denominator 191 · Adjusted rate 5.48% |
| Healthcare-associated infections requiring hospitalization | 4.85% |
7.12%
2.3 pts better
|
No Different than the National Rate · Eligible stays 193 · Observed rate 2.59% · Lower 95% interval 2.78% |
| Staff COVID-19 vaccination coverage | 0.42% |
8.2%
7.8 pts worse
|
Numerator 1 · Denominator 237 |
| Staff flu vaccination coverage | 23.4% |
42%
18.6 pts worse
|
Numerator 62 · Denominator 265 |
| Discharge function score | 60.32% |
56.45%
3.9 pts better
|
Numerator 76 · Denominator 126 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 59 · Denominator 59 |
| Transfer of health information to patient | 98.77% |
96.28%
2.5 pts better
|
Numerator 80 · Denominator 81 |
| Resident COVID-19 vaccinations up to date | 18.28% |
25.2%
6.9 pts worse
|
Numerator 17 · Denominator 93 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
1.8
0.4 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.3 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.4 |
1.8
0.6 pts worse
|
1.8
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 2.4 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
91.5%
8.2 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 98.9% · 4Q avg 99.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.0% |
94.1%
4.9 pts better
|
95.5%
3.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.6% |
3.6%
About the same
|
3.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 3.3% · Q3 2.5% · Q4 4.6% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.2% |
4.8%
2.4 pts worse
|
11.4%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 9.9% · Q3 4.5% · Q4 9.0% · 4Q avg 7.2% |
| Percentage of long-stay residents who lose too much weight | 7.0% |
7.2%
0.2 pts better
|
5.4%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.4% · Q2 9.5% · Q3 6.8% · Q4 7.5% · 4Q avg 7.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 9.5% |
21.6%
12.1 pts better
|
19.6%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 9.4% · Q3 9.6% · Q4 7.5% · 4Q avg 9.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 13.7% |
15.0%
1.3 pts better
|
16.7%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 13.2% · Q3 13.2% · Q4 15.1% · 4Q avg 13.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 3.4% |
0.0%
3.4 pts worse
|
0.1%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 3.3% · Q3 3.7% · Q4 3.4% · 4Q avg 3.4% |
| Percentage of long-stay residents whose ability to walk independently worsened | 14.6% |
21.5%
6.9 pts better
|
16.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.3% · Q2 8.2% · Q3 19.4% · Q4 19.5% · 4Q avg 14.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.1% |
16.8%
10.7 pts better
|
14.9%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q2 3.9% · Q3 7.6% · Q4 8.3% · 4Q avg 6.1% · 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 0.0% · Q2 0.9% · Q3 1.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 4.5% |
2.6%
1.9 pts worse
|
1.7%
2.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 2.2% · Q3 3.7% · Q4 5.7% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.9% |
21.2%
6.7 pts worse
|
19.8%
8.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.6% · Q2 25.4% · Q3 19.7% · Q4 34.1% · 4Q avg 27.9% |
| Percentage of long-stay residents with pressure ulcers | 4.5% |
6.0%
1.5 pts better
|
5.1%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 5.7% · Q3 5.0% · Q4 4.2% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 94.3% |
79.9%
14.4 pts better
|
81.7%
12.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 91.2% · Q2 94.7% · Q3 94.1% · Q4 96.7% · 4Q avg 94.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 25.6% |
13.2%
12.4 pts worse
|
12.0%
13.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.6% · Observed 25.0% · Expected 10.9% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.9% |
1.5%
0.4 pts worse
|
1.6%
0.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 3.9% · Q3 2.4% · Q4 0.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.6% |
78.1%
13.5 pts better
|
79.7%
11.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 21.6% |
22.9%
1.3 pts better
|
23.9%
2.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 21.6% · Observed 20.3% · Expected 22.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-24 · Fire 2023-03-02
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
2 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Cycle 3
Health 2023-03-02 · Fire 2021-07-30
7 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-07-24
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-10-11
F · Potential for more than minimal harm
2024-07-24
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-10-11
E · Potential for more than minimal harm
2024-07-24
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-10-11
E · Potential for more than minimal harm
2024-07-24
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-07-24
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-07-24
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 2024-10-11
D · Potential for more than minimal harm
2024-07-24
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-07-24
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-07-24
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-10-11
D · Potential for more than minimal harm
2024-07-24
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-10-11
D · Potential for more than minimal harm
2023-03-02
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-04-25
D · Potential for more than minimal harm
2023-03-02
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 2023-04-25
E · Potential for more than minimal harm
2021-07-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2021-10-13
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-17
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-11-27
J · Immediate jeopardy
2024-07-24
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 2024-08-13
J · Immediate jeopardy
2024-07-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-13
D · Potential for more than minimal harm
2024-07-24
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-08-13
D · Potential for more than minimal harm
2024-07-24
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 2024-08-13
B · Minimal harm
2024-07-24
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2024-08-13
F · Potential for more than minimal harm
2023-03-02
F802 · Nutrition and Dietary Deficiencies
Health
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
Corrected 2023-03-28
F · Potential for more than minimal harm
2023-03-02
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2023-03-28
F · Potential for more than minimal harm
2023-03-02
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 2023-03-28
D · Potential for more than minimal harm
2023-03-02
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 2023-03-28
D · Potential for more than minimal harm
2023-03-02
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-03-28
D · Potential for more than minimal harm
2023-03-02
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-03-28
B · Minimal harm
2023-03-02
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 2023-03-28
Penalties and ownership
What sits behind the stars
$15,646
2024-07-24
Fine
Fine · fine $15,646
Fine
Ownership
Avant & Nunn, LLC
5% Or Greater Direct Ownership Interest · Organization
Avant & Nunn, LLC
5% Or Greater Mortgage Interest · Organization
Avant, Keith
5% Or Greater Direct Ownership Interest · Individual
Avant, Keith
Corporate Director · Individual
Bullard, Judith
Corporate Director · Individual
Bullard, Judith
W-2 Managing Employee · Individual
Nunn, Deborah
5% Or Greater Direct Ownership Interest · Individual
Nearby options
Other facilities in reach
#1
Davis Health Care Center
Wilmington, NC
2-star overall rating with 2-star inspections with $96,849 in total fines with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Davis Health and Wellness Center at Cambridge Vill
Wilmington, NC
3-star overall rating with 3-star inspections with $5,244 in total fines with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Northchase Nursing and Rehabilitation Center
Wilmington, NC
2-star overall rating with 2-star inspections with $7,901 in total fines with 8 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
Jump out