Average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Stokes County Nursing Home during CMS and state inspections, most recent first.
Surveyors found that the facility’s 2025 facility-wide assessment did not include a written contingency plan, informed by the assessment, to address nursing staff and other resource availability during non-emergency events that could affect resident care, potentially impacting all 38 residents. The Assistant Administrator reported being unaware that such a contingency plan was required in the assessment, and the DON confirmed there was no written plan outlining actions for events that could interrupt resident care. The Administrator stated the assessment was reviewed annually but acknowledged that the contingency plan was not included, despite ongoing management turnover.
The facility failed to complete required Abnormal Involuntary Movement Scale (AIMS) assessments for multiple residents receiving antipsychotic medications. One resident on nightly olanzapine had only a single AIMS documented despite a care plan intervention calling for AIMS testing per protocol. Another resident on daily olanzapine, who was severely cognitively impaired and received antipsychotics per the MDS, had no AIMS assessments and no care plan intervention addressing AIMS. A third resident on scheduled quetiapine with documented behavioral symptoms and a prior GDR also had no AIMS assessments and no care plan focus on antipsychotic use. Interviews with the DON, consultant pharmacist, medical director, physician, and administrator showed they were unaware of AIMS frequency requirements, believed AIMS might be captured in the MDS or EMR, and lacked a tracking process, leading to missed and overdue AIMS assessments.
A resident with dementia, anxiety disorder with psychotic features, and recurrent major depressive disorder was readmitted and later restarted on routine Quetiapine for anxiety and depression, as documented in physician orders, the MAR, and MDS assessments. Despite ongoing administration of the antipsychotic and documented behavioral observations, the comprehensive care plan did not include any plan addressing antipsychotic use. The DON was unaware of the omission, the MDS coordinator reported she was in training and not creating care plans, and the Administrator, who was assisting with care plans, acknowledged the care plan was not updated after the antipsychotic was resumed following the resident’s hospital discharge and readmission.
Surveyors found that the facility did not post oxygen-in-use safety signage for three residents who were receiving continuous or ordered oxygen therapy via nasal cannula at 2 lpm for conditions including Streptococcus pyogenes and COPD, despite documentation and repeated observations confirming active oxygen use. Staff interviews revealed that a NA and a nurse had not seen oxygen-in-use signs in the facility and relied on shift report to know which residents were on oxygen. The DON and Administrator stated that, because the campus was smoke free and no smoking signs were posted, they believed there was no need to place oxygen precaution signs on residents’ doors.
The facility failed to ensure the Pharmacy Consultant identified and reported missing Abnormal Involuntary Movement Scale (AIMS) assessments during monthly drug regimen reviews for two residents receiving antipsychotic medications. One resident with dementia, anxiety, psychotic features, and a history of cerebral infarction was prescribed Quetiapine, but had no AIMS assessment on file, and multiple monthly reviews did not note this omission. Another resident with dementia with behaviors and generalized anxiety disorder was prescribed Olanzapine and had only one AIMS assessment documented over an extended period, with subsequent monthly reviews failing to address the need for additional assessments. The Pharmacy Consultant reported she did not believe AIMS assessments were still required and rarely looked for them, while the DON, Medical Director, Facility Physician, and Administrator all stated they were unaware that complete medical record reviews, including verification of AIMS assessments, were not being performed.
A deficiency occurred when a cognitively intact, independent resident with an above-the-knee amputation did not have an accessible bathroom call light because the pull cord was missing on repeated observations. The resident confirmed the absence of the pull cord and noted that if he were on the floor, he could not use the call system. CNAs and an OT reported the resident was independent with ADLs except for showers. The Maintenance Director stated he was unaware of the issue and that no work order had been entered in the engineering book, which review confirmed. The Environmental Service Manager’s weekly room checklist did not address call lights or pull cords, and she did not notice the missing cord during rounds. The DON and Administrator were also unaware of the missing pull cord and relied on staff to report such issues to maintenance.
The facility failed to accurately complete and post daily nurse staffing information for an extended period, leaving RN/LPN designations blank for all listed nurses and omitting shift-specific census information on multiple days and shifts. A nurse reported she only recorded census for the night shift and was unaware that RN/LPN status had to be documented next to each nurse’s name. The DON was unclear about the required census detail and whether RN/LPN designation was mandated, while the Administrator stated that orientation training should cover full completion of the form, including census and licensure designation, yet the forms continued to be filled out incorrectly.
The facility did not submit the required PBJ staffing data to CMS for the third quarter of FY 2023 on time. The Administrator, responsible for the submission, acknowledged the delay, attributing it to staff changes, which resulted in the data being submitted one day late.
The facility lacked a documented water management program for Legionella, potentially affecting all residents. The Infection Preventionist was unsure about the program's existence, and the Maintenance Director lacked knowledge in water management. The Administrator admitted that a written program should have been in place.
Failure to Include Staffing and Resource Contingency Plan in Facility Assessment
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its facility-wide assessment included a written contingency plan, informed by that assessment, to address the availability of nursing staff and other resources during events that did not require activation of the formal emergency plan but had the potential to affect resident care. Record review of the 2025 facility assessment showed that it did not identify or contain such a contingency plan for staffing and resources for non-emergency events. This omission had the potential to affect all 38 residents in the facility. During interviews, the Assistant Administrator stated she was unaware that a contingency plan for staffing and resources for non-emergency events needed to be addressed in the facility assessment and was uncertain why it had not been completed. The DON confirmed there was no written plan specifying what to do when the facility experienced an event that could affect resident care and did not know why such a plan was not in place. The Administrator reported that the facility assessment was reviewed and revised annually but acknowledged that the written contingency plan informed by the assessment was not included, noting that management turnover beginning in 2025 had been complex, while recognizing the facility still had the responsibility to meet the facility assessment requirements.
Failure to Perform Required AIMS Assessments for Residents on Antipsychotic Medications
Penalty
Summary
The deficiency involves the facility’s failure to conduct ongoing Abnormal Involuntary Movement Scale (AIMS) assessments for residents receiving antipsychotic medications. For one resident with dementia with behaviors and generalized anxiety disorder, the physician ordered nightly olanzapine 2.5 mg, and the active care plan identified a risk for complications related to psychotropic and antipsychotic medications with an intervention specifying AIMS testing per protocol. However, the medical record contained only a single AIMS assessment dated 3/10/25, with no additional AIMS assessments found. Another resident, admitted with unspecified dementia without behavior, psychotic disturbance, mood disturbance, and anxiety, had a physician order for daily olanzapine 5 mg. The active care plan for this resident included interventions to monitor and document side effects and effectiveness of olanzapine but did not include any intervention for completing an AIMS assessment. The quarterly MDS documented that this resident was severely cognitively impaired and received antipsychotic medications, yet review of the medical record revealed no AIMS assessments had been completed. A third resident, readmitted with diagnoses including unspecified dementia with behavioral disturbance, anxiety disorder with delusional thoughts and harmful behaviors, major depressive disorder with paranoia and restlessness, and a history of cerebral infarction, had an active care plan after readmission that did not address antipsychotic medication. A subsequent physician order prescribed quetiapine 50 mg in the morning and 100 mg at bedtime for anxiety disorder and recurrent major depressive disorder. The quarterly MDS showed this resident was cognitively intact, had verbal behaviors toward others on some days, and routinely received antipsychotic and antidepressant medications, with the last GDR documented on 5/19/25. Despite this, there were no AIMS assessments in the medical record. Interviews with the DON, consultant pharmacist, medical director, facility physician, and administrator revealed a lack of awareness of AIMS requirements, absence of a process to track when AIMS were due, and system and staffing changes that contributed to AIMS assessments not being completed as needed.
Failure to Update Care Plan for Antipsychotic Medication Use
Penalty
Summary
The deficiency involves the facility’s failure to revise a comprehensive care plan to address the use of an antipsychotic medication for one resident. The resident was readmitted with diagnoses including dementia with behavioral disturbance, anxiety disorder, anxiety with psychotic features, and recurrent unspecified major depressive disorder. A review of the active comprehensive care plan dated 6/10/25 showed no care plan addressing antipsychotic medication use. Physician orders dated 6/29/25 directed administration of Quetiapine Fumarate 50 mg by mouth in the morning and 100 mg at bedtime for unspecified anxiety disorder and unspecified recurrent major depressive disorder, and the MAR from June through November 2025 confirmed the medication was administered as ordered with observations for side effects and behaviors three times daily. Quarterly MDS assessments documented that the resident was cognitively intact, had verbal behaviors toward others on some days during one look-back period, and was routinely receiving antipsychotic medications. Interviews with facility staff further clarified the circumstances leading to the deficiency. The DON stated she was unaware that the resident’s care plan did not include an antipsychotic medication plan but acknowledged that one should have been in place, and reported that the MDS coordinator or Administrator created and updated care plans. The MDS coordinator reported she was in training and not responsible for creating care plans, stating that the Administrator was responsible for initiating and updating them. The Administrator acknowledged that the resident’s care plan did not include an antipsychotic medication care plan and explained that the previous MDS coordinator had created care plans, and that she had assisted with creating and updating them during the new MDS coordinator’s training. She stated the care plan was missing because the resident had been discharged to the hospital and readmitted without an antipsychotic order, and when behaviors later emerged and the antipsychotic was restarted on 6/29/25, the care plan was not updated to reflect the resumed antipsychotic therapy.
Failure to Post Oxygen-In-Use Safety Signage for Residents on Oxygen Therapy
Penalty
Summary
The facility failed to provide appropriate respiratory care by not posting cautionary and safety signage indicating oxygen use for three residents receiving oxygen therapy. One resident with Streptococcus pyogenes had a physician order for continuous oxygen via nasal cannula at 2 liters per minute (lpm) to maintain oxygen saturation above 90%, and the resident’s MDS documented oxygen use. Multiple observations over several days showed this resident in bed with oxygen at 2 lpm and no cautionary or safety signage posted at the room. Another resident with chronic obstructive pulmonary disease (COPD) had a physician order for oxygen at 2 lpm via nasal cannula, and observations on several occasions found the resident in the room using oxygen without any oxygen-in-use signage posted. A third resident with COPD had physician orders for continuous oxygen via nasal cannula at 2 lpm to keep oxygen saturation above 90%, and the MDS also documented oxygen use. Observations on multiple dates and times showed this resident in bed receiving oxygen at 2 lpm with no cautionary or safety signage at the room. During interviews, a nurse aide stated she did not recall ever seeing oxygen-in-use signs on residents’ doors and learned which residents were on oxygen only during shift report, and a nurse reported not seeing any oxygen-in-use signs posted in the facility. The DON stated that precaution signs for oxygen were not needed because the facility was smoke free, and the Administrator similarly stated that with no smoking signs posted throughout the campus and being a smoke-free facility, there was no need for oxygen cautionary signs on residents’ doors.
Failure of Pharmacy Consultant to Identify Missing AIMS Assessments During Monthly Drug Regimen Reviews
Penalty
Summary
The deficiency involves the facility’s Pharmacy Consultant failing to identify and report irregularities related to required Abnormal Involuntary Movement Scale (AIMS) assessments during monthly drug regimen reviews for residents receiving antipsychotic medications. One resident was readmitted with diagnoses including unspecified dementia with behavioral disturbance, anxiety disorder with delusional thoughts and harmful behaviors, recurrent major depressive disorder, paranoia, restlessness, and a history of cerebral infarction. This resident had physician orders for Quetiapine Fumarate, an antipsychotic, but the medical record contained no AIMS assessment. Despite this, multiple monthly drug regimen reviews by the Pharmacy Consultant over several months did not document any need for an AIMS assessment. Another resident was readmitted with dementia with behaviors and generalized anxiety disorder and had an order for Olanzapine, an antipsychotic, with only one AIMS assessment on file since the last recertification survey. Subsequent monthly drug regimen reviews for this resident also lacked any notation that additional AIMS assessments were needed. Interviews further clarified the inactions contributing to the deficiency. The Pharmacy Consultant stated she did not think AIMS assessments still needed to be completed for residents on antipsychotic medications and reported that she rarely reviewed AIMS assessments unless staff reported possible side effects, adding that she had not seen AIMS forms in residents’ records. The DON reported being unaware whether the Pharmacy Consultant reviewed medical records for AIMS assessments and indicated that the Administrator reviewed the Pharmacy Consultant’s reports monthly. The Medical Director and Facility Physician both stated they were not aware that the Pharmacy Consultant was not performing complete medical record reviews that would include checking for AIMS assessments, and the Facility Physician stated he would expect a full medical record review each month. The Administrator reported she was unaware that AIMS assessments were not being reviewed and expected the Pharmacy Consultant to identify and report irregularities, including the need for AIMS assessments, during monthly drug regimen reviews, but did not realize this was not occurring when reviewing the monthly reports.
Failure to Maintain Accessible Bathroom Call Light for Independent Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a working and accessible call light system was available in a resident's bathroom and bathing area. The resident involved had an above-the-knee amputation of the left leg and was assessed as cognitively intact and independent with transfers, bed mobility, toileting, and other ADLs. On multiple observations over three consecutive days, the bathroom call light for this resident was found without an attached pull cord. The resident confirmed that there was no pull cord in the bathroom, could not recall when it was last present, and stated that if he were lying on the floor, he would be unable to use the call light for assistance. Staff interviews showed that nursing assistants and the occupational therapist considered the resident independent in daily care tasks, with assistance only needed for showers. The Facility Maintenance Director reported having a preventative maintenance program but stated it had not been completed and that he was unaware of the missing pull cord because no one had notified him or entered a request in the engineering book. Review of the engineering book showed no service request for the missing pull cord during the specified period. The Environmental Service Manager used a weekly checklist that did not include call lights or pull cords and did not notice the missing pull cord during her room rounds. The DON and Administrator both stated they were unaware of the missing pull cord and indicated that staff were expected to communicate such issues to maintenance via the engineering book or direct calls, but this did not occur in this case.
Failure to Accurately Complete and Post Daily Nurse Staffing Information
Penalty
Summary
The deficiency involves the facility’s failure to post accurate daily nurse staffing information for all 30 days reviewed. Record review of daily nurse staffing sheets showed that the RN/LPN designation was not indicated for the assigned nurses on any of the forms. In addition, the resident census was left blank for both the morning (7:00 AM–3:00 PM) and evening (3:00 PM–11:00 PM) shifts on multiple dates, and was also left blank for the evening shift on several other dates. These omissions meant that the posted staffing forms did not contain complete information on nurse licensure level or shift-specific census as required. During interviews, a nurse reported she had been trained during orientation by an LPN preceptor and knew all areas of the form needed to be completed, but she only documented the census for the 11:00 PM–7:00 AM shift because the number could change on other shifts, and she was not aware that RN or LPN designation needed to be listed beside each nurse’s name. The DON stated she was unsure how training on the daily staffing report was completed, believed the census was per day rather than per shift, and did not know whether listing RN/LPN designation was a state requirement or a facility process. The Administrator stated that nurses received training during orientation, that all areas of the report including census should be completed, and that each nurse’s RN or LPN designation should be listed, but acknowledged the reports were being completed incorrectly.
Failure to Submit PBJ Staffing Data on Time
Penalty
Summary
The facility failed to electronically submit direct care staffing information based on payroll data to the Centers for Medicare and Medicaid Services (CMS) for the third quarter of fiscal year 2023, covering the period from April 1 to June 30, 2023. This deficiency was identified during a review of the Payroll Based Journal (PBJ) Staffing Data report from the Certification and Survey Provider Enhanced Reports (CASPER) database, which revealed that the required data was not submitted. An interview with the Administrator confirmed that she was responsible for submitting the PBJ data and acknowledged that the submission was late due to staff changes, resulting in the data being submitted one day after the deadline.
Lack of Legionella Water Management Program
Penalty
Summary
The facility failed to have a documented water management program for Legionella, which had the potential to affect all 34 residents. A review of the facility's Emergency Preparedness Plan and Infection Control policies showed no evidence of such a program. During an interview, the Infection Preventionist (IP) was unsure about the existence of a written water management program for Legionella. The Administrator indicated that the IP was responsible for overseeing water management, but the Maintenance Director lacked knowledge in this area. The Administrator acknowledged that there should have been a written Legionella water management program in place.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Danbury
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Walnut Cove Health And Rehabilitation | 9.4 mi | ★★★★★ | 7 | 0 |
| King Health And Rehabilitation Center | 12.2 mi | ★★★★★ | 0 | 0 |
| Village Care Of King | 13.1 mi | ★★★★★ | 3 | 0 |
| Blue Ridge Therapy Connection | 15.3 mi | ★★★★★ | 7 | 0 |
| Oak Forest Health And Rehabilitation | 15.4 mi | ★★★★★ | 0 | 0 |
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