Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Summerstone Health And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with bilateral hand contractures had therapy and physician orders, as well as a care plan and MAR entries, directing that bilateral palm guards be worn daily for several hours with removal only for ROM, hygiene, eating, and ADL care. Over multiple observations, the resident’s hands remained contracted, the palm guards were not in use or present in the room, and the resident reported he had not worn them in a long time and had not refused them. Staff interviews showed that NAs were expected to apply the devices and nurses to verify their use, but the assigned nurse could not recall when the resident last wore them, and an NA reported the palm guards had not been seen for a long time and appeared to be lost, despite MAR entries indicating they had been applied.
A resident with end-stage renal disease, cognitively intact and on a regular diet, had no upper teeth and reported two remaining upper back teeth that needed extraction before being fitted for a partial denture. Since admission, there was no documentation of any dental examination, and the care plan contained no dental information. The resident stated she had repeatedly asked nurses to see a dentist but was told the dentist visited while she was at dialysis. The Appointment Scheduler reported she had not been informed of these requests and confirmed, after reviewing records, that the resident had not been seen by a dentist and was not included on the list for the most recent on-site dental visit.
A resident with diabetes and bilateral hand contractures, who required dependent assistance for hygiene and nail care and had intact cognition with no rejection of care, did not receive ordered daily nail cleaning and weekly trimming. Physician orders and the MAR specified daily diabetic nail care on the day shift, but surveyors repeatedly observed the resident’s fingernails to be long and dirty with visible debris. Day- and night-shift NAs reported assuming the other shift had bathed the resident, did not perform nail care, and in one case did not report difficulty cleaning contracted hands to nursing. The assigned nurse acknowledged the nail care orders, had not assessed the nails that morning, and the MAR was not initialed for diabetic nail care, resulting in the resident’s ongoing lack of proper nail hygiene.
The facility failed to ensure daily posted nurse staffing sheets accurately reflected the number and type of nursing staff who actually worked. On multiple reviewed days, posted counts of LPNs and NAs did not match the nursing assignment sheets, with both overstatements and understatements of staff. The DON, who was solely responsible for scheduling and posting staffing information and had no staff scheduling coordinator or reconciliation process, acknowledged that postings were not updated when staff called out or left early and that an RN had been counted as an LPN. The Administrator confirmed the DON’s responsibility for staffing postings and was unable to explain the inaccuracies.
A cognitively impaired resident was allowed to exit a facility after a NA mistakenly identified him as a visitor. The resident, who had dementia, was found 1.4 miles away after traversing multiple roads in cold weather. The responsible nurse failed to immediately activate the elopement process, delaying police notification and increasing the risk of harm.
The facility failed to properly label, date, and store food items in their walk-in freezer, including an open box of corn on the cob and expired ice cream. The Dietary Manager acknowledged the issue, stating staff had been educated on proper procedures. The DON confirmed the expectation for proper food storage, but the Administrator was unavailable for comment.
A resident with dementia was discharged from an LTC facility without proper documentation or communication with the resident's representative. The facility failed to provide written reasons for the discharge or document efforts to meet the resident's needs. The discharge form was not signed by the representative, and there was confusion about the discharge decision, leading to a deficiency in the process.
A resident was discharged from an LTC facility without a referral for home health services, despite recommendations from physical and occupational therapy for continued therapy at home. The social worker did not follow the physician's discharge order, believing it was standard and due to uncertainty about the family's new address. The Director of Rehabilitation and the resident had agreed on the discharge plan, but the necessary referrals were not made.
A resident with osteoarthritis and mobility decline fell from her bed during incontinence care when a NA provided care alone, contrary to the care plan requiring two staff for assistance. The resident was sent to the ED for evaluation, where no injuries were found. The incident highlighted a failure to provide safe care and adequate supervision.
A resident with a history of recurrent UTIs and ESBL was discharged from the hospital with instructions to receive two doses of fosfomycin. However, due to an error in transcribing the order into the facility's system, only one dose was administered. This significant medication error was confirmed through interviews with the nurse practitioner, director of nursing, and the dispensing pharmacy.
A resident with a history of bladder dysfunction and UTIs was observed with her urinary catheter bag and tubing in contact with the floor on multiple occasions. Despite staff awareness, the issue persisted, indicating a failure in maintaining proper infection control practices. The DON acknowledged the deficiency, noting it should have been addressed promptly.
A facility experienced a 10.3% medication error rate due to incorrect administration of aspirin and acetaminophen to two residents. A nurse gave a chewable aspirin instead of the prescribed enteric-coated version and administered acetaminophen too soon after a previous dose. Another nurse misplaced an aspirin tablet during preparation, requiring a replacement to be administered. The DON confirmed expectations for adherence to the 5 rights of medication administration.
The facility failed to store medications properly and remove expired ones from med carts. An unopened bottle of latanoprost eye drops was found unrefrigerated on a med cart, contrary to storage instructions. Additionally, two expired bottles of Magic Mouthwash were found on another cart, with one requiring refrigeration. Nurses confirmed the storage errors, and the DON emphasized the importance of following storage instructions and removing expired medications.
A nurse failed to follow the facility's infection control policy during wound care for a resident by not performing hand hygiene after removing gloves. The nurse handled clean supplies with unclean hands and returned unused supplies to the treatment cart without cleansing his hands. The DON and Administrator confirmed that staff are expected to adhere to hand hygiene protocols, which were not followed in this instance.
Failure to Apply Ordered Palm Guards for Resident With Hand Contractures
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered care to maintain range of motion for a dependent resident with bilateral hand contractures. The resident had been evaluated by therapy, which determined he had reached maximum potential and required daily use of bilateral palm guards to maintain mobility and prevent skin irritation. Physician orders and the care plan directed that palm guards be worn on both hands for 6 hours daily or as tolerated, with removal only for ROM exercises, eating, hygiene, and ADL care, and with daily skin checks. The MAR for March documented that palm guards were to be applied up to 6 hours daily and showed they were signed as applied at 9:00 AM from the 1st through the 18th. During multiple observations over several days, surveyors noted the resident’s hands were in loose-fisted contracted positions and that the ordered palm guards were not on his hands and were not present in his room. The resident reported he had palm guards but had not worn them in a long time, stated he had not refused them, and said he would wear them as ordered. Staff interviews revealed that nurse aides were expected to apply the palm guards after care and nurses were to ensure they were in place, but the assigned nurse could not recall when she last saw the resident wearing them and had not yet completed the treatment on the day of review. A nurse aide stated she had not seen the palm guards in a long time and believed they had been lost, and attempts to locate them were unsuccessful. Therapy confirmed that palm guards had been issued and that nursing was responsible for their ongoing application under a functional maintenance program, but the DON reported she had not been informed that the palm guards were missing.
Failure to Arrange Requested Dental Services for a Resident
Penalty
Summary
The facility failed to obtain routine dental services when requested for a resident with missing upper teeth. The resident was cognitively intact, had end-stage renal disease, and received regular consistency food with thin liquids, with no documented swallowing disorders, dental problems, or significant weight loss on the MDS. Since admission, there was no evidence in the medical record that the resident had been examined by a dentist, and the active care plan contained no information related to dental care. During observation, the resident was noted to have no upper teeth and reported having two remaining upper back teeth that needed extraction before being fitted for a partial denture. The resident stated that she had requested to see a dentist from several nurses but was told that the dentist’s on-site visits occurred while she was away at dialysis, which was scheduled three times per week. She reported not having seen a dentist since admission, though she had experienced mouth pain in the past from the remaining upper teeth. The Appointment Scheduler explained that residents requesting dental services should be added to a list for the next on-site visit or scheduled for an outside appointment if they could not be seen during on-site hours, and that the facility would arrange transportation. However, the Appointment Scheduler reported she had not been informed by nursing staff of this resident’s requests, and a review of dental appointment records confirmed the resident had not been seen by a dentist and was not on the list for the most recent on-site dental visit.
Failure to Provide Ordered Diabetic Nail Care for Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered nail care as part of activities of daily living (ADL) for a dependent resident with diabetes and bilateral hand contractures. The resident had a physician’s order for daily nail cleaning and weekly trimming on the 7:00 AM to 7:00 PM shift as part of diabetic care, and the March Medication Administration Record (MAR) indicated that diabetic care, including fingernail cleaning and trimming as needed, should be completed daily. The resident’s quarterly MDS and care plan documented that the resident had intact cognition, limited range of motion in both hands, used hand guards, required dependent care for hygiene and nail care, and had no rejection of care. Despite this, surveyor observations on multiple days showed the resident’s fingernails on both hands were long and dirty, with brown matter under the thumbs and whitish substance under other fingers, and the resident reported it had been a long time since staff cleaned or cut his nails and that nail care was not offered. Staff interviews and record reviews further demonstrated that the ordered nail care was not being provided. Nursing assistants on both day and night shifts reported assumptions that the other shift had bathed the resident and did not perform or ensure nail care, with one aide acknowledging she had not noticed the nails needed cleaning and another stating she did not bathe the resident on consecutive days because she believed night shift had done so. A night-shift aide stated she bathed the resident but did not clean or trim the nails due to the resident’s contracted hands and did not report the nail condition to nursing. The nurse assigned to the resident acknowledged the physician’s order for daily cleaning and weekly trimming, agreed the nails needed care, and had not assessed the nails that morning; the MAR for that day was not initialed for diabetic nail care. Throughout these observations and interviews, there was no indication that the resident refused care, yet the resident’s nails remained long and dirty over several days.
Inaccurate Daily Nurse Staffing Postings
Penalty
Summary
The deficiency involves the facility’s failure to ensure that daily posted nurse staffing sheets accurately reflected the actual number of nursing staff who worked on multiple reviewed days. Surveyors compared the daily posted nurse staffing sheets with the nursing staff assignment sheets and found discrepancies on four of seven days reviewed. On one day, the posted sheet showed 9 LPNs and 22 NAs, while the assignment sheet showed 6 LPNs and 27 NAs. On another day, the posted sheet indicated 8 LPNs and 24 NAs, but the assignment sheet documented 3 LPNs and 11 NAs. A third day’s posting listed 10 LPNs and 27 NAs, whereas the assignment sheet showed 11 LPNs and 23 NAs. On a fourth day, the posted sheet showed 10 LPNs, while the assignment sheet showed 11 LPNs. During interviews, the DON stated she was responsible for both creating nursing staff schedules and completing and posting the daily staffing sheets, as there was no Staff Scheduling Coordinator. She explained that if a nursing staff member called out or left early, the daily staffing posting sheet should have been adjusted, but acknowledged that this was not done. She also stated that one discrepancy between posted and scheduled LPNs occurred because an RN was counted as an LPN. The DON reported she was unaware that the posting sheets were incorrect on the identified dates and confirmed that no one reconciled the nurse staff schedules with the daily posted staffing sheets. The Administrator confirmed that the DON was responsible for posting and updating the daily nurse staffing sheets, could not explain why they were inaccurate, and stated he was not involved in the staff posting sheets but expected them to display correct information.
Resident Elopement Due to Staff Error and Delayed Response
Penalty
Summary
The facility failed to protect a cognitively impaired resident, identified as Resident #6, who was allowed to exit the facility through the locked main entrance door. This incident occurred when a Nurse Aide (NA) unlocked and opened the door for the resident, mistakenly believing he was a visitor. The resident, who had been admitted with diagnoses including dementia and congestive heart failure, was found 1.4 miles away from the facility in the parking lot of a restaurant near a gas station. The resident had to traverse multiple roads, including a divided 4-lane road and a 4-lane highway, in cold weather conditions while wearing inappropriate clothing for the weather. The resident's care plan indicated he was a wanderer and at risk for elopement due to wandering behavior and disorientation. However, the resident had not exhibited exit-seeking behaviors prior to the incident. On the night of the incident, the resident approached NA #1 and requested to be let out of the building, which the NA complied with, thinking the resident was a visitor. Nurse #1, who was responsible for the resident during the shift, failed to immediately implement the elopement process upon realizing the resident was missing. Instead, she conducted a search on her own before notifying the Nursing Supervisor, which delayed the activation of the elopement protocol. The facility's failure to immediately contact the police and implement the elopement process upon discovering the resident was missing contributed to the high likelihood of serious harm. The resident's cognitive impairment, exposure to cold weather, and the distance traveled increased the risk of harm. The incident highlighted deficiencies in staff training and adherence to the facility's elopement prevention policy, as well as the need for improved supervision and monitoring of residents at risk for elopement.
Removal Plan
- Resident #6 was placed on 1:1 supervision and an elopement transmitter was applied.
- The care plan and Kardex were updated to reflect the elopement risk and the elopement transmitter.
- The facility conducted a 100% audit on all current residents to ensure they were present and accounted for.
- The facility completed a 100% audit on all current residents to ensure wandering assessments were accurate and appropriate interventions were in place.
- The facility checked and updated the elopement books to ensure they were accurate and up to date.
- The Staff Development Clinician initiated an in-service for all staff on the Elopement Prevention policy.
- Training included checking the placement of transmitter bracelets and batteries, monitoring new admissions with high risk or at risk to wander, and completing risk assessments on admission, quarterly, and as needed.
- The facility implemented a policy to never let a person out of the facility without referencing the elopement book and consulting a nurse.
- The facility established initial and secondary search procedures for missing residents.
- The Director of Nursing and Unit Manager will audit all admission and readmission risk assessments.
- Staff knowledge checks will be completed using the Mock Elopement Drill Knowledge Checks Audit Tool.
- Reports of the results will be presented to the QA committee to ensure corrective action is implemented and effective.
- All new staff members will complete the elopement process training before their first shift at the facility.
Improper Food Storage and Labeling in Walk-In Freezer
Penalty
Summary
The facility failed to properly label, date, and store food items in their walk-in freezer, as observed during a survey. The survey revealed an open box of corn on the cob, an opened and undated box of turkey sausage, an opened and undated box of hot dogs, an opened and undated box of hamburger patties, and a partially used container of vanilla ice cream with an expired date. The Dietary Manager, who had been in the role for a few weeks, acknowledged that staff had been educated on the proper procedures for labeling, dating, and storing food. However, the expectation that food should be dated and discarded after three days if partially used was not met. The Director of Nursing confirmed that all stored foods should be dated and properly wrapped if opened. The Administrator was not available for comment.
Inadequate Discharge Documentation and Communication
Penalty
Summary
The facility failed to provide adequate documentation and communication regarding the discharge of a resident, identified as Resident #205, who had dementia and a history of repeated falls. The resident was admitted with intact cognition but later experienced cognitive decline and severe impairment. Despite the resident's representative being informed of the need for a higher level of care, the facility did not provide written documentation stating the specific needs they could not meet, nor did they document efforts to meet those needs or the services the receiving facility would provide. The discharge process was mishandled, as the resident was transferred to a local nursing facility with a memory care unit without the resident's representative signing the discharge form. Interviews with staff revealed that the resident's representative was not present at the time of discharge, and there was a lack of clarity and communication regarding the discharge decision. The social worker involved in the process was no longer employed at the facility, and her phone number was disconnected, further complicating the situation. The resident's representative expressed dissatisfaction with the discharge, stating that she was not informed prior to the day of discharge and had previously declined the facility to which the resident was transferred. The representative had agreed to a discharge to a facility closer to her, but this was not honored. The facility's documentation and communication failures led to a deficiency in the discharge process, as the necessary steps and approvals were not properly followed or documented.
Failure to Ensure Safe Discharge with Home Health Services
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for a resident who was discharged home without a referral for home health services. The resident, who had been admitted with a diagnosis of stroke, was ambulatory and able to walk with supervision, and required supervision for certain activities of daily living. Both physical and occupational therapy discharge summaries recommended home health services to continue therapy at home. However, the discharge summary signed by the social worker did not include a request for home services, despite a physician's order for home physical and occupational therapy. Interviews revealed that the Director of Rehabilitation had discussed the discharge plan with the resident, who was cognitively intact and agreed to the plan to return home with family and continue therapy. The social worker was aware of the physician's discharge order but did not follow through, mistakenly believing the order was standard and due to uncertainty about the family's new address. The nurse practitioner confirmed that the social worker should have made the referral as ordered, and the administrator acknowledged the social worker's failure to follow the physician's discharge order.
Resident Falls from Bed During Incontinence Care
Penalty
Summary
The facility failed to provide care in a safe manner when a dependent resident rolled off her bed onto the floor during incontinence care. The incident involved a resident who was admitted with a diagnosis of osteoarthritis and had a significant change in her Minimum Data Set indicating mobility decline, pressure ulcer, and a fall. The resident required extensive assistance with bed mobility and was always incontinent of bowel and bladder. During the incident, a Nursing Assistant (NA) was providing care alone and turned the resident, resulting in the resident rolling off the bed. The resident complained of pain in her head and right hip, and was sent to the Emergency Department for evaluation, where no injuries were found. The care plan for the resident documented an increased risk for falls and required assistance with activities of daily living, including bed mobility. The NA involved in the incident did not use two staff members for assistance, which was necessary for a dependent resident to prevent rolling out of bed. Interviews with the staff, including the Nurse Practitioner and Director of Nursing, confirmed the incident and the lack of awareness regarding the use of side rails. The resident was assessed and returned from the hospital with no injuries, although she had a history of osteoarthritis in both knees and hips.
Failure to Administer Full Course of Antibiotic Treatment
Penalty
Summary
The facility failed to correctly transcribe and administer the full course of an antibiotic treatment for a resident who was discharged from the hospital with a urinary tract infection (UTI). The resident, who had a history of recurrent UTIs and ESBL, was supposed to receive two doses of fosfomycin, an oral antibiotic, starting on a specific date. However, the order was incorrectly transcribed by a nurse into the electronic medical record, resulting in only one dose being administered. The resident's hospital discharge summary clearly indicated that two doses of fosfomycin were to be given, with specific start and end dates. Despite this, the nurse responsible for transcribing the order into the facility's system entered an incorrect start date, leading to the omission of the first dose. This error was not caught until later, and the resident only received one dose of the medication, which was documented in the Medication Administration Record. Interviews with the nurse practitioner and the facility's director of nursing confirmed the error in transcription and administration. The nurse practitioner noted that the resident's family reported increased confusion, prompting further testing for a UTI. The dispensing pharmacy also confirmed that only one dose of the medication was requested and delivered. The facility's failure to administer the full course of the prescribed antibiotic treatment was identified as a significant medication error.
Infection Control Deficiency with Urinary Catheter Management
Penalty
Summary
The facility failed to maintain proper infection control practices for a resident with an indwelling urinary catheter. The resident, who had a history of neuromuscular dysfunction of the bladder and urinary tract infections, was observed multiple times with her urinary catheter bag and tubing in contact with the floor. On several occasions, the catheter bag was either hanging too low from the wheelchair or not attached at all, resulting in the bag and tubing lying on the floor. This was observed on three separate days, indicating a repeated failure to ensure the catheter was properly secured. Interviews with staff, including a nurse aide and the facility's Staff Development Coordinator, who also served as the Infection Preventionist, confirmed awareness of the issue. The nurse aide acknowledged the problem and had informed a nurse, while the Infection Preventionist confirmed that the catheter bag and tubing should not be on the floor. The Director of Nursing also acknowledged the deficiency, expressing that the issue should have been addressed immediately by the staff when first identified.
Medication Administration Errors Result in 10.3% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a 10.3% error rate during the observation of medication administration for two residents. Nurse #1 administered an incorrect formulation of aspirin to Resident #32, providing a chewable tablet instead of the prescribed enteric-coated delayed-release tablet. Additionally, Nurse #1 administered a second dose of acetaminophen to the same resident only 1 hour and 48 minutes after the first dose, contrary to the 8-hour interval specified in the medication order. Nurse #2, while preparing medications for Resident #86, misplaced an 81 mg enteric-coated delayed-release aspirin tablet. The nurse was unaware of the missing tablet until prompted to check the medication cup, at which point he retrieved another tablet from the medication cart to administer to the resident. This incident highlights a lapse in ensuring the right dosage and dosage form during medication administration. The Director of Nursing (DON) confirmed that the nursing staff is expected to adhere to the 5 rights of medication administration, including the correct dosage and dosage form. The DON also acknowledged that the premature administration of PRN acetaminophen to Resident #32 should not have occurred and emphasized the importance of checking documentation to verify the timing of previous doses.
Medication Storage and Expiration Deficiencies
Penalty
Summary
The facility failed to store medications according to the manufacturer's instructions and did not remove expired medications from the medication carts. During an observation of the 200 Hall Med Cart, an unopened bottle of latanoprost eye drops was found stored on the cart instead of being refrigerated as required by the manufacturer's instructions. The pharmacy label indicated the medication was dispensed for a resident two days prior to the observation, and a pharmacy auxiliary sticker on the container specified that the medication should be refrigerated until opened. Nurse #4 confirmed that the eye drop bottle was unopened and should have been stored in the refrigerator. Additionally, an observation of the 300 Hall Med Cart revealed two bottles of Magic Mouthwash, which were labeled with an expiration date that had already passed. The pharmacy label indicated the medication was dispensed for another resident, and an auxiliary sticker on one of the bottles instructed that it should be kept refrigerated. Nurse #5 acknowledged that both bottles of Magic Mouthwash were expired and should have been stored in the refrigerator. The Director of Nursing confirmed that nursing staff are expected to follow special storage instructions and remove expired medications from the med carts.
Infection Control Deficiency in Wound Care
Penalty
Summary
The facility failed to adhere to its infection control policy and procedure for hand hygiene during wound care for Resident #408. Nurse #3 did not perform hand hygiene after removing gloves while providing wound care, which is a requirement according to the facility's hand hygiene policy. The policy specifies that hand hygiene should be performed after contact with body fluids, non-intact skin, wound dressings, and after removing gloves. During the observation, Nurse #3 removed soiled dressings, discarded them, and exited the room without cleansing his hands. He then handled clean wound care supplies with unclean hands, placed them on the resident's bed, and returned unused supplies to the treatment cart without performing hand hygiene. The Director of Nursing and the Administrator confirmed that the staff are expected to follow the hand hygiene policy, which includes washing hands before wound care, between glove changes, and after completing wound care. They also stated that wound care supplies that come into contact with the resident's environment should be discarded. Nurse #3 admitted to not placing a barrier down for supplies and was unaware of not cleaning his hands between glove changes. This incident highlights a lapse in following the established infection control procedures, which could potentially compromise resident safety.
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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 Kernersville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| North Carolina State Veterans Home Kernersville | 0 mi | — | 0 | 0 |
| Piney Grove Nursing And Rehabilitation Center | 1.8 mi | — | 1 | 0 |
| River Landing At Sandy Ridge | 5.7 mi | — | 2 | 0 |
| Trinity Glen | 6.5 mi | — | 2 | 0 |
| Willow Valley Center For Nursing And Rehabilitatio | 10.2 mi | — | 3 | 0 |
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