Cycle 1
Health 2024-11-21 · Fire 2024-11-21
5 health deficiencies
Top issue: Resident Rights (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Warrenton, NC
Warren Hills Nursing Center
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
864 US HWY 158 Business West, Warrenton, NC
(252) 257-2011
Overall
4 / 5
CMS overall stars
Health inspections
4 / 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
140
Certified beds
Average residents
90
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Liberty Senior Living
Operator or chain grouping
Approved since
1983-12-01
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
0.38
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.92
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.36
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.66
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.30
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.28
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.31
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
0.40
CMS adjusted RN staffing hours
Adjusted total hours
3.81
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
57%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
2,879
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
47.20
Composite VBP score used to determine payment impact.
Payment multiplier
1.0007
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.76
Baseline 21.36% · Performance 18.76% · Measure score 5.76 · Achievement 5.76 · Improvement 5.50
Healthcare-associated infections
8.19
Baseline 10.42% · Performance 5.71% · Measure score 8.19 · Achievement 7.12 · Improvement 8.19
Total nurse turnover
2.55
Baseline 50.63% · Performance 53.26% · Measure score 2.55 · Achievement 2.55 · Improvement 0
Adjusted total nurse staffing
2.38
Baseline 3.44 hours · Performance 3.76 hours · Measure score 2.38 · Achievement 2.38 · Improvement 0.84
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.77% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 76 · Observed rate 11.84% · Lower 95% interval 7.42% |
| Discharge to community | 31.95% |
50.57%
18.6 pts worse
|
Worse than the National Rate · Eligible stays 79 · Observed rate 22.78% · Lower 95% interval 23.34% |
| Medicare spending per beneficiary | 0.92 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 42 · Denominator 42 |
| Falls with major injury | 2.38% |
0.77%
1.6 pts worse
|
Numerator 1 · Denominator 42 |
| Discharge self-care score | 66.67% |
53.69%
13 pts better
|
Numerator 20 · Denominator 30 |
| Discharge mobility score | 73.33% |
50.94%
22.4 pts better
|
Numerator 22 · Denominator 30 |
| Pressure ulcers or injuries, new or worsened | 4.76% |
2.29%
2.5 pts worse
|
Numerator 2 · Denominator 42 · Adjusted rate 6.11% |
| Healthcare-associated infections requiring hospitalization | 5.71% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 43 · Observed rate 0% · Lower 95% interval 3.45% |
| Staff COVID-19 vaccination coverage | 5.66% |
8.2%
2.5 pts worse
|
Numerator 6 · Denominator 106 |
| Staff flu vaccination coverage | 13.11% |
42%
28.9 pts worse
|
Numerator 16 · Denominator 122 |
| Discharge function score | 66.67% |
56.45%
10.2 pts better
|
Numerator 20 · Denominator 30 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 13 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 20 · Denominator 20 |
| Resident COVID-19 vaccinations up to date | 13.04% |
25.2%
12.2 pts worse
|
Numerator 3 · Denominator 23 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 85.7% |
91.5%
5.8 pts worse
|
93.4%
7.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 92.3% · Q2 93.2% · Q3 85.0% · Q4 73.5% · 4Q avg 85.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 91.5% |
94.1%
2.6 pts worse
|
95.5%
4 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 91.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.6% |
3.6%
2 pts better
|
3.3%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 1.4% · Q3 0.0% · Q4 2.4% · 4Q avg 1.6% · 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 | 9.5% |
7.2%
2.3 pts worse
|
5.4%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q2 10.8% · Q3 8.6% · Q4 12.2% · 4Q avg 9.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.7% |
21.6%
7.9 pts better
|
19.6%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 13.4% · Q3 11.4% · Q4 17.6% · 4Q avg 13.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.4% |
15.0%
4.6 pts better
|
16.7%
6.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.5% · Q2 9.8% · Q3 8.8% · Q4 11.5% · 4Q avg 10.4% · 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 | 11.1% |
21.5%
10.4 pts better
|
16.3%
5.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.2% · Q2 8.8% · Q3 4.0% · Q4 14.6% · 4Q avg 11.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.1% |
16.8%
8.7 pts better
|
14.9%
6.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 14.3% · Q3 4.6% · Q4 4.3% · 4Q avg 8.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.4% |
0.9%
2.5 pts worse
|
1.0%
2.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 2.6% · Q3 2.9% · Q4 4.1% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.9% |
2.6%
0.7 pts better
|
1.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.0% · Q4 6.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.3% |
21.2%
3.1 pts worse
|
19.8%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.2% · Q2 31.5% · Q3 13.9% · Q4 17.4% · 4Q avg 24.3% |
| Percentage of long-stay residents with pressure ulcers | 10.9% |
6.0%
4.9 pts worse
|
5.1%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.0% · Q2 13.4% · Q3 11.7% · Q4 8.0% · 4Q avg 10.9% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 25.8% |
79.9%
54.1 pts worse
|
81.7%
55.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 47.5% · Q2 24.1% · Q3 17.6% · Q4 18.3% · 4Q avg 25.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 20.7% |
13.2%
7.5 pts worse
|
12.0%
8.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 20.7% · Observed 20.5% · Expected 11.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.2% |
1.5%
1.7 pts worse
|
1.6%
1.6 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.1% · Q3 6.4% · Q4 2.0% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 20.5% |
78.1%
57.6 pts worse
|
79.7%
59.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 20.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.3% |
22.9%
1.4 pts worse
|
23.9%
0.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.3% · Observed 20.5% · Expected 20.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-14 · Fire 2023-09-14
5 health deficiencies
Top issue: Administration (1 deficiency)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-04-08 · Fire 2022-04-08
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-11-21
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2025-02-07
D · Potential for more than minimal harm
2024-11-21
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-02-07
D · Potential for more than minimal harm
2024-11-21
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 2025-02-07
D · Potential for more than minimal harm
2024-11-21
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-02-07
D · Potential for more than minimal harm
2023-09-14
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-11-14
D · Potential for more than minimal harm
2023-09-14
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-11-14
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-11-21
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-12-16
D · Potential for more than minimal harm
2024-11-21
F559 · Resident Rights Deficiencies
Health
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Corrected 2024-12-16
D · Potential for more than minimal harm
2024-11-21
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 2024-12-16
D · Potential for more than minimal harm
2024-11-21
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 2024-12-16
B · Minimal harm
2024-11-21
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 2024-12-16
E · Potential for more than minimal harm
2023-09-14
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 2023-10-03
E · Potential for more than minimal harm
2023-09-14
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-09-27
D · Potential for more than minimal harm
2023-09-14
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-09-27
D · Potential for more than minimal harm
2023-09-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-09-29
D · Potential for more than minimal harm
2023-09-14
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-09-29
F · Potential for more than minimal harm
2022-04-08
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 2022-05-24
E · Potential for more than minimal harm
2022-04-08
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2022-05-24
E · Potential for more than minimal harm
2022-04-08
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 2022-05-24
E · Potential for more than minimal harm
2022-04-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-05-24
D · Potential for more than minimal harm
2022-04-08
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2022-05-24
C · Minimal harm
2022-04-08
F570 · Resident Rights Deficiencies
Health
Assure the security of all personal funds of residents deposited with the facility.
Corrected 2022-05-24
Penalties and ownership
What sits behind the stars
Ownership
Bogonko, Nelson
Operational/Managerial Control · Individual
Calcutt, Joeseph V
Corporate Officer · Individual
Kenney, James
Operational/Managerial Control · Individual
Miller, Robert
Corporate Director · Individual
Wilson, Jeffrey
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Camellia Gardens Center for Nursing and Rehab
Henderson, NC
1-star overall rating with 1-star inspections with $74,576 in total fines with 7 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Kerr Lake Nursing and Rehabilitation Center
Henderson, NC
3-star overall rating with 3-star inspections with $32,269 in total fines with 2 recent health deficiencies
#3
Senior Citizens Home
Henderson, NC
2-star overall rating with 2-star inspections with $55,760 in total fines with 6 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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