Cycle 1
Health 2025-01-10 · Fire 2025-01-10
10 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Kernersville, NC
Summerstone Health and Rehabilitation Center
2-star overall rating with 2-star inspections with $14,511 in total fines with 10 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
485 Veterans Way, Kernersville, NC
(336) 515-3000
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
138
Certified beds
Average residents
117
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Liberty Senior Living
Operator or chain grouping
Approved since
1978-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
35 facilities
Chain averages 3 overall / 3 health / 2 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
0.32
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.86
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.28
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.46
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.18
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.12
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.23
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
0.34
CMS adjusted RN staffing hours
Adjusted total hours
3.67
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
67%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,440
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.74
Composite VBP score used to determine payment impact.
Payment multiplier
0.9843
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.34
Baseline 23.15% · Performance 20.80% · Measure score 3.34 · Achievement 1.37 · Improvement 3.34
Healthcare-associated infections
5.25
Baseline 7.39% · Performance 6.27% · Measure score 5.25 · Achievement 5.25 · Improvement 4.19
Total nurse turnover
1.07
Baseline 79.63% · Performance 71.05% · Measure score 1.07 · Achievement 0 · Improvement 1.07
Adjusted total nurse staffing
1.04
Baseline 2.98 hours · Performance 3.37 hours · Measure score 1.04 · Achievement 1.04 · Improvement 0.89
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.29% |
10.72%
1.4 pts better
|
No Different than the National Rate · Eligible stays 126 · Observed rate 8.73% · Lower 95% interval 6.49% |
| Discharge to community | 58.5% |
50.57%
7.9 pts better
|
No Different than the National Rate · Eligible stays 132 · Observed rate 50.76% · Lower 95% interval 50.33% |
| Medicare spending per beneficiary | 0.89 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 82.61% |
95.27%
12.7 pts worse
|
Numerator 76 · Denominator 92 |
| Falls with major injury | 2.17% |
0.77%
1.4 pts worse
|
Numerator 2 · Denominator 92 |
| Discharge self-care score | 40.98% |
53.69%
12.7 pts worse
|
Numerator 25 · Denominator 61 |
| Discharge mobility score | 45.9% |
50.94%
5 pts worse
|
Numerator 28 · Denominator 61 |
| Pressure ulcers or injuries, new or worsened | 2.17% |
2.29%
0.1 pts better
|
Numerator 2 · Denominator 92 · Adjusted rate 1.64% |
| Healthcare-associated infections requiring hospitalization | 6.27% |
7.12%
0.9 pts better
|
No Different than the National Rate · Eligible stays 80 · Observed rate 5% · Lower 95% interval 3.72% |
| Staff COVID-19 vaccination coverage | 3.67% |
8.2%
4.5 pts worse
|
Numerator 4 · Denominator 109 |
| Staff flu vaccination coverage | 10.43% |
42%
31.6 pts worse
|
Numerator 12 · Denominator 115 |
| Discharge function score | 45.9% |
56.45%
10.6 pts worse
|
Numerator 28 · Denominator 61 |
| Transfer of health information to provider | 97.83% |
95.95%
1.9 pts better
|
Numerator 45 · Denominator 46 |
| Transfer of health information to patient | 86.21% |
96.28%
10.1 pts worse
|
Numerator 25 · Denominator 29 |
| Resident COVID-19 vaccinations up to date | 2.33% |
25.2%
22.9 pts worse
|
Numerator 1 · Denominator 43 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.3% |
91.5%
0.2 pts worse
|
93.4%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 93.2% · Q2 91.9% · Q3 89.6% · Q4 90.8% · 4Q avg 91.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.4% |
94.1%
2.7 pts worse
|
95.5%
4.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.2% |
3.6%
0.6 pts worse
|
3.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 5.4% · Q3 3.9% · Q4 4.6% · 4Q avg 4.2% · 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 10.3% |
7.2%
3.1 pts worse
|
5.4%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.8% · Q2 14.9% · Q3 5.9% · Q4 3.6% · 4Q avg 10.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.3% |
21.6%
5.3 pts better
|
19.6%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 16.4% · Q3 14.7% · Q4 16.9% · 4Q avg 16.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.2% |
15.0%
5.8 pts better
|
16.7%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 11.7% · Q3 6.7% · Q4 7.9% · 4Q avg 9.2% · 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 | 19.0% |
21.5%
2.5 pts better
|
16.3%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q3 22.0% · Q4 12.9% · 4Q avg 19.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.3% |
16.8%
10.5 pts better
|
14.9%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.9% · Q2 1.6% · Q3 4.6% · Q4 6.4% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.4% |
0.9%
0.5 pts worse
|
1.0%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.0% · Q2 1.4% · Q3 0.9% · Q4 2.1% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
2.6%
1 pts better
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 2.7% · Q3 1.3% · Q4 1.1% · 4Q avg 1.6% · 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 26.5% · Q2 33.0% · Q3 29.6% · Q4 23.4% · 4Q avg 27.9% |
| Percentage of long-stay residents with pressure ulcers | 7.7% |
6.0%
1.7 pts worse
|
5.1%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 4.1% · Q3 8.8% · Q4 10.1% · 4Q avg 7.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 76.1% |
79.9%
3.8 pts worse
|
81.7%
5.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 79.8% · Q2 72.8% · Q3 66.5% · Q4 85.0% · 4Q avg 76.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.2% |
13.2%
3 pts better
|
12.0%
1.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.2% · Observed 10.7% · Expected 11.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.5% |
1.5%
1 pts better
|
1.6%
1.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.1% · Q2 0.6% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 73.0% |
78.1%
5.1 pts worse
|
79.7%
6.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 73.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 12.0% |
22.9%
10.9 pts better
|
23.9%
11.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 12.0% · Observed 13.1% · Expected 25.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-27 · Fire 2023-10-27
5 health deficiencies
Top issue: Administration (1 deficiency)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-07-21 · Fire 2022-07-21
22 health deficiencies
Top issue: Resident Rights (6 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-01-10
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2025-04-06
D · Potential for more than minimal harm
2025-01-10
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-04-06
D · Potential for more than minimal harm
2025-01-10
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-04-06
D · Potential for more than minimal harm
2025-01-10
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-04-06
D · Potential for more than minimal harm
2025-01-10
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-04-06
D · Potential for more than minimal harm
2023-10-27
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-01-12
D · Potential for more than minimal harm
2023-10-27
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 2024-01-12
D · Potential for more than minimal harm
2023-10-27
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-01-12
D · Potential for more than minimal harm
2023-10-27
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 2024-01-12
F · Potential for more than minimal harm
2022-07-21
E1 · Emergency Preparedness Deficiencies
Fire Safety
Establish an Emergency Preparedness Program (EP).
Corrected 2022-08-18
F · Potential for more than minimal harm
2022-07-21
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-11-04
D · Potential for more than minimal harm
2022-07-21
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 2022-11-04
D · Potential for more than minimal harm
2022-07-21
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-11-04
D · Potential for more than minimal harm
2022-07-21
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-11-04
D · Potential for more than minimal harm
2022-07-21
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-11-04
D · Potential for more than minimal harm
2022-07-21
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-11-04
Inspection history
Recent health citations
J · Immediate jeopardy
2025-03-03
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 2025-02-04
E · Potential for more than minimal harm
2025-01-10
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 2025-02-04
D · Potential for more than minimal harm
2025-01-10
F622 · Resident Rights Deficiencies
Health
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
Corrected 2025-02-04
D · Potential for more than minimal harm
2025-01-10
F624 · Resident Rights Deficiencies
Health
Prepare residents for a safe transfer or discharge from the nursing home.
Corrected 2025-02-04
D · Potential for more than minimal harm
2025-01-10
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 2025-02-04
D · Potential for more than minimal harm
2025-01-10
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 2025-02-04
D · Potential for more than minimal harm
2025-01-10
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-02-04
D · Potential for more than minimal harm
2025-01-10
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-02-04
D · Potential for more than minimal harm
2025-01-10
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 2025-02-04
D · Potential for more than minimal harm
2025-01-10
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-02-04
D · Potential for more than minimal harm
2023-10-27
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 2023-11-25
D · Potential for more than minimal harm
2023-10-27
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-11-25
D · Potential for more than minimal harm
2023-10-27
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-11-25
D · Potential for more than minimal harm
2023-10-27
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-10-23
D · Potential for more than minimal harm
2023-10-27
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-11-25
J · Immediate jeopardy
2022-07-21
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 2022-08-18
J · Immediate jeopardy
2022-07-21
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-08-18
J · Immediate jeopardy
2022-07-21
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 2022-08-18
G · Actual harm
2022-07-21
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2022-08-18
F · Potential for more than minimal harm
2022-07-21
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 2022-08-18
F · Potential for more than minimal harm
2022-07-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-08-18
E · Potential for more than minimal harm
2022-07-21
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-08-18
E · Potential for more than minimal harm
2022-07-21
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-08-18
E · Potential for more than minimal harm
2022-07-21
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 2022-08-18
E · Potential for more than minimal harm
2022-07-21
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2022-08-18
D · Potential for more than minimal harm
2022-07-21
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2022-08-18
D · Potential for more than minimal harm
2022-07-21
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2022-08-18
D · Potential for more than minimal harm
2022-07-21
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2022-08-18
D · Potential for more than minimal harm
2022-07-21
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 2022-08-18
D · Potential for more than minimal harm
2022-07-21
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-08-18
D · Potential for more than minimal harm
2022-07-21
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 2022-08-18
D · Potential for more than minimal harm
2022-07-21
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2022-08-18
D · Potential for more than minimal harm
2022-07-21
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 2022-08-18
D · Potential for more than minimal harm
2022-07-21
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-08-18
D · Potential for more than minimal harm
2022-07-21
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2022-08-18
D · Potential for more than minimal harm
2022-07-21
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2022-08-18
B · Minimal harm
2022-07-21
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2022-08-18
Penalties and ownership
What sits behind the stars
$14,511
2025-01-10
Fine
Fine · fine $14,511
Fine
Ownership
Liberty Long Term Care LLC
5% Or Greater Direct Ownership Interest · Organization
Bork, Matthew
Operational/Managerial Control · Individual
Calcutt, Joeseph V
Corporate Officer · Individual
Long Term Care Management Services LLC
Operational/Managerial Control · Organization
Mcneill, John
Operational/Managerial Control · Individual
Mcneill, Ronald
Operational/Managerial Control · Individual
Miller, Robert
Corporate Director · Individual
Vanderhoof, Richard
Operational/Managerial Control · Individual
Wilson, Jeffrey
Corporate Officer · Individual
Wright, Anna
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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Kernersville, NC
5-star overall rating with 5-star inspections
#2
Piney Grove Nursing and Rehabilitation Center
Kernersville, NC
3-star overall rating with 3-star inspections with $10,699 in total fines with 1 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
River Landing at Sandy Ridge
Colfax, NC
5-star overall rating with 4-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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