Cycle 1
Health 2025-02-20 · Fire 2025-02-20
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Raleigh, NC
Sunnybrook Rehabilitation Center
2-star overall rating with 2-star inspections with $72,855 in total fines with 2 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
25 Sunnybrook Road, Raleigh, NC
(919) 231-6150
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
95
Certified beds
Average residents
85
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Sovereign Healthcare Holdings
Operator or chain grouping
Approved since
1973-09-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
43 facilities
Chain averages 4 overall / 3 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
0.51
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
1.08
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.06
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.65
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.59
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.04
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.34
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.19
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.53
CMS adjusted RN staffing hours
Adjusted total hours
3.75
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
51%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,358
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
40.27
Composite VBP score used to determine payment impact.
Payment multiplier
0.9932
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.16
Baseline 23.88% · Performance 20.00% · Measure score 5.16 · Achievement 3.09 · Improvement 5.16
Healthcare-associated infections
6.22
Baseline 8.15% · Performance 6.03% · Measure score 6.22 · Achievement 6.04 · Improvement 6.22
Total nurse turnover
2.66
Baseline 69.41% · Performance 55.34% · Measure score 2.66 · Achievement 2.04 · Improvement 2.66
Adjusted total nurse staffing
2.06
Baseline 3.84 hours · Performance 3.66 hours · Measure score 2.06 · Achievement 2.06 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.91% |
10.72%
0.8 pts better
|
No Different than the National Rate · Eligible stays 281 · Observed rate 9.25% · Lower 95% interval 7.43% |
| Discharge to community | 62.9% |
50.57%
12.3 pts better
|
Better than the National Rate · Eligible stays 281 · Observed rate 56.94% · Lower 95% interval 56.51% |
| Medicare spending per beneficiary | 0.85 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 97.09% |
95.27%
1.8 pts better
|
Numerator 167 · Denominator 172 |
| Falls with major injury | 1.16% |
0.77%
0.4 pts worse
|
Numerator 2 · Denominator 172 |
| Discharge self-care score | 51.16% |
53.69%
2.5 pts worse
|
Numerator 44 · Denominator 86 |
| Discharge mobility score | 55.81% |
50.94%
4.9 pts better
|
Numerator 48 · Denominator 86 |
| Pressure ulcers or injuries, new or worsened | 4.65% |
2.29%
2.4 pts worse
|
Numerator 8 · Denominator 172 · Adjusted rate 5.02% |
| Healthcare-associated infections requiring hospitalization | 6.03% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 168 · Observed rate 4.76% · Lower 95% interval 3.46% |
| Staff COVID-19 vaccination coverage | 6.25% |
8.2%
1.9 pts worse
|
Numerator 10 · Denominator 160 |
| Staff flu vaccination coverage | 4.49% |
42%
37.5 pts worse
|
Numerator 7 · Denominator 156 |
| Discharge function score | 59.3% |
56.45%
2.8 pts better
|
Numerator 51 · Denominator 86 |
| Transfer of health information to provider | 99.18% |
95.95%
3.2 pts better
|
Numerator 121 · Denominator 122 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 13.33% |
25.2%
11.9 pts worse
|
Numerator 12 · Denominator 90 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.7 |
1.8
0.9 pts worse
|
1.9
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 3.7 · Expected 2.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.3 |
1.8
0.5 pts worse
|
1.8
0.5 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.5 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.9% |
91.5%
7.4 pts better
|
93.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 95.8% · 4Q avg 98.9% |
| 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 | 4.5% |
3.6%
0.9 pts worse
|
3.3%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 2.9% · Q3 6.2% · Q4 5.6% · 4Q avg 4.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.5% |
4.8%
2.3 pts better
|
11.4%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 3.4% · Q3 1.7% · Q4 3.1% · 4Q avg 2.5% |
| Percentage of long-stay residents who lose too much weight | 7.3% |
7.2%
0.1 pts worse
|
5.4%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 13.6% · Q3 10.7% · Q4 1.5% · 4Q avg 7.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.7% |
21.6%
10.9 pts better
|
19.6%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 9.5% · Q3 12.1% · Q4 11.8% · 4Q avg 10.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 22.8% |
15.0%
7.8 pts worse
|
16.7%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.4% · Q2 21.2% · Q3 21.6% · Q4 24.1% · 4Q avg 22.8% · 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 | 18.6% |
21.5%
2.9 pts better
|
16.3%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 23.2% · Q3 9.2% · Q4 7.7% · 4Q avg 18.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.9% |
16.8%
1.1 pts worse
|
14.9%
3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.9% · Q2 23.0% · Q3 8.9% · Q4 14.3% · 4Q avg 17.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.2% |
0.9%
0.7 pts better
|
1.0%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.0% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
2.6%
2.2 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.9% |
21.2%
5.3 pts better
|
19.8%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 18.9% · Q3 16.2% · Q4 16.2% · 4Q avg 15.9% |
| Percentage of long-stay residents with pressure ulcers | 11.3% |
6.0%
5.3 pts worse
|
5.1%
6.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.5% · Q2 12.4% · Q3 8.9% · Q4 8.7% · 4Q avg 11.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 87.3% |
79.9%
7.4 pts better
|
81.7%
5.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.6% · Q2 91.8% · Q3 87.5% · Q4 72.8% · 4Q avg 87.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.7% |
13.2%
0.5 pts better
|
12.0%
0.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.7% · Observed 12.7% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 2.2% |
1.5%
0.7 pts worse
|
1.6%
0.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.8% · Q2 2.5% · Q3 3.6% · Q4 2.2% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 93.7% |
78.1%
15.6 pts better
|
79.7%
14 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 93.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.9% |
22.9%
7 pts worse
|
23.9%
6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.9% · Observed 30.0% · Expected 23.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-11 · Fire 2024-01-11
8 health deficiencies
Top issue: Resident Rights (5 deficiencies)
10 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Cycle 3
Health 2022-09-15 · Fire 2022-09-15
5 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-02-20
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-02-20
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 2025-05-16
D · Potential for more than minimal harm
2025-02-20
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-02-20
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-02-20
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-02-20
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-02-20
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 2025-05-16
D · Potential for more than minimal harm
2025-02-20
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-05-16
E · Potential for more than minimal harm
2024-01-11
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-01-11
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-01-11
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-01-11
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-01-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-01-11
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-01-11
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-01-11
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-01-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-01-11
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-03-08
F · Potential for more than minimal harm
2022-09-15
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 2022-12-16
F · Potential for more than minimal harm
2022-09-15
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2022-12-16
F · Potential for more than minimal harm
2022-09-15
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-12-16
D · Potential for more than minimal harm
2022-09-15
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2022-12-16
D · Potential for more than minimal harm
2022-09-15
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-12-16
D · Potential for more than minimal harm
2022-09-15
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-12-16
D · Potential for more than minimal harm
2022-09-15
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2022-12-16
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-02-20
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-03-05
B · Minimal harm
2025-02-20
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 2025-03-05
D · Potential for more than minimal harm
2024-10-08
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 2024-10-18
G · Actual harm
2024-06-21
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-07-09
E · Potential for more than minimal harm
2024-06-21
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-07-09
D · Potential for more than minimal harm
2024-06-21
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 2024-07-09
D · Potential for more than minimal harm
2024-06-21
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 2024-06-07
D · Potential for more than minimal harm
2024-01-11
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 2024-01-26
D · Potential for more than minimal harm
2024-01-11
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 2024-01-26
C · Minimal harm
2024-01-11
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 2024-01-26
J · Immediate jeopardy
2023-08-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-09-08
K · Immediate jeopardy
2023-06-27
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-07-25
J · Immediate jeopardy
2023-06-27
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2023-05-23
D · Potential for more than minimal harm
2022-09-15
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2022-10-03
D · Potential for more than minimal harm
2022-09-15
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 2022-10-03
Penalties and ownership
What sits behind the stars
$10,527
2024-06-21
Fine
Fine · fine $10,527
Fine
$12,542
2024-02-15
Fine
Fine · fine $12,542
Fine
$15,593
2023-08-18
Fine
Fine · fine $15,593
Fine
$34,193
2023-06-27
Fine
Fine · fine $34,193
Fine
Ownership
Cronquist, Royce
Operational/Managerial Control · Individual
Mangine, John
Operational/Managerial Control · Individual
Mccullough, Lionel
Operational/Managerial Control · Individual
Melton, Donald
Operational/Managerial Control · Individual
Notermann, William
Operational/Managerial Control · Individual
O Brien, Patrick
Operational/Managerial Control · Individual
Southern Healthcare Management LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Capital Nursing and Rehabilitation Center
Raleigh, NC
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Tower Nursing and Rehabilitation Center
Raleigh, NC
2-star overall rating with 2-star inspections with $15,593 in total fines with 7 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Raleigh Rehabilitation Center
Raleigh, NC
2-star overall rating with 3-star inspections with $77,760 in total fines with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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