Oak Forest Health and Rehabilitation
5680 Windy Hill Drive, Winston Salem, NC 27105 · Forsyth County · 170 certified beds · avg 155 residents/day · certified since Jul 28, 1993
Part of chain: LIBERTY SENIOR LIVING (37 facilities, chain avg rating 2.8★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, one-off · Nov 8, 2024 · F-0760 · triggered by a complaint
The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Why it matters: A serious medication error can cause real harm, hospitalization, or worse.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Oct 23, 2024 (Past Non-Compliance)
▲ Actual harm, one-off · Jun 12, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jun 27, 2025 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Dec 18, 2023 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Nov 24, 2023 (Past Non-Compliance)
▲ Actual harm, repeated · Nov 15, 2022 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (H): Multiple residents were actually harmed by the same failure — a pattern of real harm, not an isolated incident.
Corrected: Nov 16, 2022 (Deficient, Provider has date of correction)
All citations in the current public record (29)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jun 12, 2025 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jun 12, 2025 | D · Potential for harm, one-off | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. · from a complaint |
| Jun 12, 2025 | D · Potential for harm, one-off | The facility did not protect residents from misuse of their belongings or money — this is called misappropriation, and it includes theft or improper use of a resident's property or funds. · from a complaint |
| Jun 12, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Jun 12, 2025 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Jun 12, 2025 | D · Potential for harm, one-off | The facility did not provide proper foot care for residents. Foot care includes routine care like nail trimming and attention to foot problems, which matter greatly for older adults. |
| Jun 12, 2025 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint |
| Jun 12, 2025 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Jun 12, 2025 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Feb 12, 2025 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · from a complaint |
| Nov 8, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. · from a complaint |
| Nov 8, 2024 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint |
| Feb 15, 2024 | F · Potential for harm, facility-wide | The facility did not dispose of garbage and refuse properly. |
| Feb 15, 2024 | F · Potential for harm, facility-wide | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. |
| Feb 15, 2024 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint |
| Feb 15, 2024 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Feb 15, 2024 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Feb 15, 2024 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Feb 15, 2024 | C · Minimal risk, facility-wide | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. |
| Dec 18, 2023 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Dec 18, 2023 | D · Potential for harm, one-off | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. · from a complaint |
| Nov 15, 2022 | ▲ H · Actual harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Nov 15, 2022 | E · Potential for harm, repeated | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Nov 15, 2022 | E · Potential for harm, repeated | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. |
| Nov 15, 2022 | D · Potential for harm, one-off | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. |
| Nov 15, 2022 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Nov 15, 2022 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Nov 15, 2022 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Nov 15, 2022 | B · Minimal risk, repeated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
Inspection trend by year
Citations from standard inspections increased between the last two inspection cycles (7 → 9).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 8 | 1 | H ▲ |
| 2023 | 2 | 1 | G ▲ |
| 2024 | 9 | 1 | J ▲ |
| 2025 | 10 | 1 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
3 fines totaling $38,527.
| Date | Type | Amount / length |
|---|---|---|
| Jun 12, 2025 | Fine | $12,948 |
| Nov 8, 2024 | Fine | $16,801 |
| Dec 18, 2023 | Fine | $8,778 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | North Carolina avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.37 | 4.01 | 3.95 | bottom 26% in North Carolina; bottom 30% in the U.S. |
| Registered Nurse hours | 0.26 | 0.64 | 0.69 | bottom 5% in North Carolina; bottom 6% in the U.S. |
| Weekend total nurse staffing | 3.12 | 3.56 | 3.50 | bottom 38% in North Carolina; bottom 37% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.25 | 0.41 | 0.48 | bottom 33% in North Carolina; bottom 22% in the U.S. |
| Total nursing staff turnover (%) | 61.3 | 49.0 | 45.8 | bottom 20% in North Carolina; bottom 15% in the U.S. |
| RN turnover (%) | 59.1 | 45.7 | 42.9 | bottom 30% in North Carolina; bottom 23% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.83, RN 0.29, weekend 3.54. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 1/5 · long-stay residents: 2/5 · short-stay residents: 1/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Liberty Healthcare Group LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 04/01/2021 |
| Calcutt, Joseph | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/01/2021 |
| Long Term Care Management Services LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 04/01/2021 |
| Miller, Robert | Individual | Corporate Director | NOT APPLICABLE | 09/01/2024 |
| Purifoy, Penny | Individual | W-2 Managing Employee | NOT APPLICABLE | 04/01/2021 |
| Weaver, Michael | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/01/2021 |
| Wilson, Jeffrey | Individual | Corporate Director | NOT APPLICABLE | 04/01/2021 |
| Wilson, Jeffrey | Individual | Operational/Managerial Control | NOT APPLICABLE | 04/01/2021 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "What choices do residents have over their daily schedule, like meal times, bathing, and activities?"
- "What safeguards do you have to protect residents' money and belongings, and what happens when something goes missing?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
- "How is routine foot care handled here, and does a podiatrist visit regularly?"
- "How do you care for residents with incontinence or catheters, and what do you do to prevent urinary tract infections?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Mill Creek Center for Nursing and Rehabilitation | 3.1 mi | Winston-Salem, NC | ★★☆☆☆ | 2/5 | |
| Brookridge Retirement Community | 3.8 mi | Winston-Salem, NC | ★★★★★ | 4/5 | |
| Salemtowne | 4.7 mi | Winston-Salem, NC | ★★★★☆ | 4/5 | |
| Arbor Acres United Methodist Retirement Community | 6.2 mi | Winston Salem, NC | ★★★★☆ | 4/5 | |
| Trinity Glen | 6.4 mi | Winston-Salem, NC | ★★★★☆ | 4/5 | |
| Willow Valley Center for Nursing and Rehabilitatio | 6.9 mi | Winston-Salem, NC | ★☆☆☆☆ | 1/5 | abuse |
| Village Care of King | 7.9 mi | King, NC | ★☆☆☆☆ | 2/5 | |
| The Oaks | 8.3 mi | Winston-Salem, NC | ★★☆☆☆ | 2/5 | |
| Silas Creek Rehabilitation Center | 8.6 mi | Winston Salem, NC | ★★★★☆ | 4/5 | |
| King Health and Rehabilitation Center | 8.7 mi | King, NC | ★★★☆☆ | 4/5 |
Compare this facility with the 3 closest →
All facilities in Winston Salem →
Facility data as of CMS processing date 2026-08-01. CCN 345443.