Cycle 1
Health 2025-08-22 · Fire 2024-07-24
11 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Winston-Salem, NC
The Oaks
1-star overall rating with 2-star inspections with 11 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
901 Bethesda Road, Winston-Salem, NC
(336) 768-2211
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
131
Certified beds
Average residents
118
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Liberty Senior Living
Operator or chain grouping
Approved since
1988-06-30
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
0.27
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.95
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.10
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.32
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.22
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
2.95
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.15
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.28
CMS adjusted RN staffing hours
Adjusted total hours
3.48
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
89%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
69%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,306
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.19
Composite VBP score used to determine payment impact.
Payment multiplier
0.9845
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.88
Baseline 21.33% · Performance 20.10% · Measure score 2.88 · Achievement 2.88 · Improvement 2.37
Healthcare-associated infections
7.04
Baseline 6.37% · Performance 5.73% · Measure score 7.04 · Achievement 7.04 · Improvement 4.14
Total nurse turnover
0
Baseline 55.77% · Performance 70.09% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0.96
Baseline 3.50 hours · Performance 3.35 hours · Measure score 0.96 · Achievement 0.96 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.28% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 88 · Observed rate 11.36% · Lower 95% interval 6.81% |
| Discharge to community | 50.2% |
50.57%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 93 · Observed rate 40.86% · Lower 95% interval 37.68% |
| Medicare spending per beneficiary | 0.77 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 89.47% |
95.27%
5.8 pts worse
|
Numerator 34 · Denominator 38 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 38 |
| Discharge self-care score | 24.14% |
53.69%
29.5 pts worse
|
Numerator 7 · Denominator 29 |
| Discharge mobility score | 24.14% |
50.94%
26.8 pts worse
|
Numerator 7 · Denominator 29 |
| Pressure ulcers or injuries, new or worsened | 10.53% |
2.29%
8.2 pts worse
|
Numerator 4 · Denominator 38 · Adjusted rate 8.37% |
| Healthcare-associated infections requiring hospitalization | 5.73% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 37 · Observed rate 0% · Lower 95% interval 2.95% |
| Staff COVID-19 vaccination coverage | 0.96% |
8.2%
7.2 pts worse
|
Numerator 1 · Denominator 104 |
| Staff flu vaccination coverage | 18.94% |
42%
23.1 pts worse
|
Numerator 25 · Denominator 132 |
| Discharge function score | 20.69% |
56.45%
35.8 pts worse
|
Numerator 6 · Denominator 29 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 90% |
96.28%
6.3 pts worse
|
Numerator 18 · Denominator 20 |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.7% |
91.5%
8.2 pts better
|
93.4%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.0% · Q3 100.0% · Q4 100.0% · 4Q avg 99.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.1% |
94.1%
4 pts better
|
95.5%
2.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.9% |
3.6%
1.7 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.1% · Q3 3.2% · Q4 2.1% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.4% |
4.8%
2.6 pts worse
|
11.4%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 9.8% · Q3 7.3% · Q4 7.2% · 4Q avg 7.4% |
| Percentage of long-stay residents who lose too much weight | 11.5% |
7.2%
4.3 pts worse
|
5.4%
6.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.6% · Q2 14.8% · Q3 8.5% · Q4 8.2% · 4Q avg 11.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.7% |
21.6%
2.9 pts better
|
19.6%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.9% · Q2 19.8% · Q3 18.3% · Q4 20.9% · 4Q avg 18.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.1% |
15.0%
4.9 pts better
|
16.7%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 10.0% · Q3 12.1% · Q4 11.3% · 4Q avg 10.1% · 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 · Q1 43.3% · 4Q avg 18.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.5% |
16.8%
5.3 pts better
|
14.9%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.8% · Q2 16.2% · Q3 11.7% · Q4 1.2% · 4Q avg 11.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
0.9%
0.2 pts worse
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 1.3% · Q3 0.7% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.2% |
2.6%
0.6 pts worse
|
1.7%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 6.2% · Q3 1.1% · Q4 2.1% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.7% |
21.2%
4.5 pts worse
|
19.8%
5.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.6% · Q2 24.2% · Q3 24.8% · Q4 24.2% · 4Q avg 25.7% |
| Percentage of long-stay residents with pressure ulcers | 8.8% |
6.0%
2.8 pts worse
|
5.1%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 9.0% · Q3 7.5% · Q4 6.7% · 4Q avg 8.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.1% |
79.9%
11.2 pts better
|
81.7%
9.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.9% · Q2 89.5% · Q3 88.2% · Q4 93.2% · 4Q avg 91.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.4% |
13.2%
0.8 pts better
|
12.0%
0.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.4% · Observed 13.5% · Expected 12.2% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.5%
0.2 pts worse
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.2% · Q3 1.7% · Q4 0.8% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 81.9% |
78.1%
3.8 pts better
|
79.7%
2.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 81.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.7% |
22.9%
1.8 pts worse
|
23.9%
0.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.7% · Observed 27.0% · Expected 26.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-24 · Fire 2023-09-15
5 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-09-15 · Fire 2022-07-08
8 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
2 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-07-24
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-09-18
D · Potential for more than minimal harm
2024-07-24
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-09-18
D · Potential for more than minimal harm
2023-09-15
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2023-11-10
D · Potential for more than minimal harm
2023-09-15
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-11-10
D · Potential for more than minimal harm
2023-09-15
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-11-10
D · Potential for more than minimal harm
2022-07-08
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 2022-08-19
D · Potential for more than minimal harm
2022-07-08
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 2022-08-19
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-08-22
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2025-09-11
F · Potential for more than minimal harm
2025-08-22
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 2025-09-11
F · Potential for more than minimal harm
2025-08-22
F814 · Nutrition and Dietary Deficiencies
Health
Dispose of garbage and refuse properly.
Corrected 2025-09-11
F · Potential for more than minimal harm
2025-08-22
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 2025-09-11
D · Potential for more than minimal harm
2025-08-22
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 2025-09-11
D · Potential for more than minimal harm
2025-08-22
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-09-11
D · Potential for more than minimal harm
2025-08-22
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-09-11
D · Potential for more than minimal harm
2025-08-22
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-09-11
D · Potential for more than minimal harm
2025-08-22
F825 · Quality of Life and Care Deficiencies
Health
Provide or get specialized rehabilitative services as required for a resident.
Corrected 2025-09-11
D · Potential for more than minimal harm
2025-08-22
F914 · Environmental Deficiencies
Health
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Corrected 2025-09-11
B · Minimal harm
2025-08-22
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 2025-09-11
E · Potential for more than minimal harm
2024-07-24
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-08-06
E · Potential for more than minimal harm
2024-07-24
F791 · Quality of Life and Care Deficiencies
Health
Provide or obtain dental services for each resident.
Corrected 2024-08-06
D · Potential for more than minimal harm
2024-07-24
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2024-08-06
D · Potential for more than minimal harm
2024-07-24
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 2024-03-07
D · Potential for more than minimal harm
2024-07-24
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 2024-08-06
E · Potential for more than minimal harm
2023-09-15
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-10-04
E · Potential for more than minimal harm
2023-09-15
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-10-04
E · Potential for more than minimal harm
2023-09-15
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-10-04
D · Potential for more than minimal harm
2023-09-15
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-10-04
D · Potential for more than minimal harm
2023-09-15
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 2023-10-04
D · Potential for more than minimal harm
2023-09-15
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-10-04
B · Minimal harm
2023-09-15
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 2023-10-04
B · Minimal harm
2023-09-15
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 2023-10-04
Penalties and ownership
What sits behind the stars
Ownership
Calcutt, Joeseph V
W-2 Managing Employee · Individual
Keener, Garrett
W-2 Managing Employee · Individual
Liberty Healthcare Group LLC
5% Or Greater Direct Ownership Interest · Organization
Liberty Long Term Care LLC
5% Or Greater Direct Ownership Interest · Organization
Mcneill, John
5% Or Greater Direct Ownership Interest · Individual
Mcneill, John
W-2 Managing Employee · Individual
Mcneill, Ronald
5% Or Greater Direct Ownership Interest · Individual
Mcneill, Ronald
W-2 Managing Employee · Individual
Miller, Robert
Corporate Director · Individual
Purifoy, Penny
W-2 Managing Employee · Individual
Wilson, Jeffrey
Corporate Director · Individual
Wilson, Jeffrey
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Silas Creek Rehabilitation Center
Winston Salem, NC
5-star overall rating with 5-star inspections with 5 fire-safety deficiencies in the latest cycle
#2
Homestead Hills
Winston-Salem, NC
5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
#3
Willow Valley Center for Nursing and Rehabilitatio
Winston-Salem, NC
1-star overall rating with 1-star inspections with $283,330 in total fines with 9 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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