Cycle 1
Health 2025-11-21 · Fire 2024-08-12
7 health deficiencies
Top issue: Administration (1 deficiency)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Danbury, NC
Stokes County Nursing Home
3-star overall rating with 3-star inspections with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1570 NC 8 and 89 Highway, Danbury, NC
(336) 593-2831
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
40
Certified beds
Average residents
40
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Lifebrite Hospital Group
Operator or chain grouping
Approved since
1977-06-13
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
2 facilities
Chain averages 2 overall / 2 health / 4 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
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
0.79
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.79
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.05
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.62
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.58
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.05
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.45
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.00
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.89
CMS adjusted RN staffing hours
Adjusted total hours
4.10
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
60%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
31%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,688
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
43.11
Composite VBP score used to determine payment impact.
Payment multiplier
0.9961
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
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
7.93
Baseline 42.86% · Performance 31.25% · Measure score 7.93 · Achievement 7.93 · Improvement 5.95
Adjusted total nurse staffing
0.69
Baseline 3.12 hours · Performance 3.27 hours · Measure score 0.69 · Achievement 0.69 · Improvement 0.07
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Medicare spending per beneficiary | Not Available |
1.02
|
No data were submitted for this measure. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator Not Available · Adjusted rate Not Available · No data were submitted for this measure. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Staff COVID-19 vaccination coverage | 1.56% |
8.2%
6.6 pts worse
|
Numerator 2 · Denominator 128 |
| Staff flu vaccination coverage | 78.45% |
42%
36.5 pts better
|
Numerator 91 · Denominator 116 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 86.1% |
91.5%
5.4 pts worse
|
93.4%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 75.8% · Q2 100.0% · Q3 77.1% · Q4 90.0% · 4Q avg 86.1% |
| 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 | 0.0% |
3.6%
3.6 pts better
|
3.3%
3.3 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 who have depressive symptoms | 0.8% |
4.8%
4 pts better
|
11.4%
10.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.9% · 4Q avg 0.8% |
| Percentage of long-stay residents who lose too much weight | 2.4% |
7.2%
4.8 pts better
|
5.4%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 6.2% · Q4 2.9% · 4Q avg 2.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 47.7% |
21.6%
26.1 pts worse
|
19.6%
28.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 48.4% · Q2 50.0% · Q3 50.0% · Q4 42.9% · 4Q avg 47.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 31.9% |
15.0%
16.9 pts worse
|
16.7%
15.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 27.6% · Q2 34.5% · Q3 34.5% · Q4 31.2% · 4Q avg 31.9% · 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 | 24.2% |
21.5%
2.7 pts worse
|
16.3%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 24.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.8% |
16.8%
1 pts better
|
14.9%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.4% · Q2 14.8% · Q3 20.7% · Q4 12.5% · 4Q avg 15.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
0.9%
0.1 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.8% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.0% |
2.6%
2.4 pts worse
|
1.7%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 5.9% · Q3 2.9% · Q4 7.5% · 4Q avg 5.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.4% |
21.2%
1.2 pts worse
|
19.8%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.1% · Q2 13.5% · Q3 29.0% · Q4 17.6% · 4Q avg 22.4% |
| Percentage of long-stay residents with pressure ulcers | 3.8% |
6.0%
2.2 pts better
|
5.1%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.7% · Q3 5.4% · Q4 6.3% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 65.4% |
79.9%
14.5 pts worse
|
81.7%
16.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 65.4% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-12 · Fire 2023-03-09
2 health deficiencies
Top issue: Administration (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-03-09 · Fire 2021-07-09
6 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
1 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-08-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-07
D · Potential for more than minimal harm
2021-07-09
K111 · Construction Deficiencies
Fire Safety
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Corrected 2021-08-06
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-11-21
F838 · Administration Deficiencies
Health
Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.
Corrected 2026-02-03
D · Potential for more than minimal harm
2025-11-21
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-11-26
D · Potential for more than minimal harm
2025-11-21
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 2026-01-16
D · Potential for more than minimal harm
2025-11-21
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-12-12
D · Potential for more than minimal harm
2025-11-21
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2026-01-13
D · Potential for more than minimal harm
2025-11-21
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2026-01-13
C · Minimal harm
2025-11-21
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2025-12-05
F · Potential for more than minimal harm
2024-08-12
F851 · Administration Deficiencies
Health
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
Corrected 2024-09-05
F · Potential for more than minimal harm
2024-08-12
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-05
F · Potential for more than minimal harm
2023-03-09
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 2023-03-15
E · Potential for more than minimal harm
2023-03-09
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2023-05-22
D · Potential for more than minimal harm
2023-03-09
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2023-03-30
D · Potential for more than minimal harm
2023-03-09
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-03-30
D · Potential for more than minimal harm
2023-03-09
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-05-12
C · Minimal harm
2023-03-09
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-03-31
Penalties and ownership
What sits behind the stars
Ownership
Lifebrite Hospital Group LLC
5% Or Greater Direct Ownership Interest · Organization
Amber Dominique Fletcher 2018 Trust
5% Or Greater Indirect Ownership Interest · Organization
Fletcher 2018 Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Fletcher, Amber
Operational/Managerial Control · Individual
Fletcher, Amber
Corporate Officer · Individual
Fletcher, Christian
5% Or Greater Indirect Ownership Interest · Individual
Fletcher, Christian
Operational/Managerial Control · Individual
Fletcher, Christian
Corporate Officer · Individual
Lifebrite Hospital Group LLC
Operational/Managerial Control · Organization
Lifebrite Laboratories, LLC
5% Or Greater Indirect Ownership Interest · Organization
Tillman, Pamela
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Walnut Cove Health and Rehabilitation
Walnut Cove, NC
2-star overall rating with 2-star inspections with $40,149 in total fines with 4 recent health deficiencies with 11 fire-safety deficiencies in the latest cycle
#2
King Health and Rehabilitation Center
King, NC
2-star overall rating with 3-star inspections with 7 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Village Care of King
King, NC
1-star overall rating with 2-star inspections with $110,113 in total fines with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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