Cycle 1
Health 2025-08-07 · Fire 2024-07-18
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Raleigh, NC
Capital Nursing and Rehabilitation Center
4-star overall rating with 4-star inspections with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
3000 Holston Lane, Raleigh, NC
(919) 231-6045
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
125
Certified beds
Average residents
100
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Liberty Senior Living
Operator or chain grouping
Approved since
1980-10-01
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
0.47
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.83
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
3.40
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.29
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.04
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.32
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.48
CMS adjusted RN staffing hours
Adjusted total hours
3.49
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
47%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,781
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
42.71
Composite VBP score used to determine payment impact.
Payment multiplier
0.9957
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.44
Baseline 19.42% · Performance 18.45% · Measure score 6.44 · Achievement 6.44 · Improvement 3.56
Healthcare-associated infections
6.68
Baseline 6.22% · Performance 5.84% · Measure score 6.68 · Achievement 6.68 · Improvement 2.64
Total nurse turnover
2.96
Baseline 56.79% · Performance 51.58% · Measure score 2.96 · Achievement 2.96 · Improvement 1.13
Adjusted total nurse staffing
1
Baseline 3.26 hours · Performance 3.36 hours · Measure score 1 · Achievement 1 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.02% |
10.72%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 149 · Observed rate 11.41% · Lower 95% interval 8.34% |
| Discharge to community | 52.19% |
50.57%
1.6 pts better
|
No Different than the National Rate · Eligible stays 143 · Observed rate 46.85% · Lower 95% interval 43.43% |
| Medicare spending per beneficiary | 0.84 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 97.5% |
95.27%
2.2 pts better
|
Numerator 78 · Denominator 80 |
| Falls with major injury | 1.25% |
0.77%
0.5 pts worse
|
Numerator 1 · Denominator 80 |
| Discharge self-care score | 43.75% |
53.69%
9.9 pts worse
|
Numerator 28 · Denominator 64 |
| Discharge mobility score | 17.19% |
50.94%
33.8 pts worse
|
Numerator 11 · Denominator 64 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 80 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.84% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 88 · Observed rate 3.41% · Lower 95% interval 3.54% |
| Staff COVID-19 vaccination coverage | 6.72% |
8.2%
1.5 pts worse
|
Numerator 8 · Denominator 119 |
| Staff flu vaccination coverage | 16.67% |
42%
25.3 pts worse
|
Numerator 26 · Denominator 156 |
| Discharge function score | 28.13% |
56.45%
28.3 pts worse
|
Numerator 18 · Denominator 64 |
| Transfer of health information to provider | 93.75% |
95.95%
2.2 pts worse
|
Numerator 60 · Denominator 64 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 4 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 27.27% |
25.2%
2.1 pts better
|
Numerator 9 · Denominator 33 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.9% |
91.5%
6.4 pts better
|
93.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.7% · Q2 96.2% · Q3 97.8% · Q4 98.9% · 4Q avg 97.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 95.2% |
94.1%
1.1 pts better
|
95.5%
0.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 95.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.6% |
3.6%
3 pts better
|
3.3%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.3% · Q3 0.0% · Q4 0.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.5% |
4.8%
2.3 pts better
|
11.4%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 0.0% · Q3 0.0% · Q4 7.1% · 4Q avg 2.5% |
| Percentage of long-stay residents who lose too much weight | 4.4% |
7.2%
2.8 pts better
|
5.4%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 3.2% · Q3 5.5% · Q4 5.4% · 4Q avg 4.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.4% |
21.6%
13.2 pts better
|
19.6%
11.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 7.9% · Q3 8.2% · Q4 6.8% · 4Q avg 8.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.4% |
15.0%
3.6 pts better
|
16.7%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 13.8% · Q3 10.9% · Q4 9.2% · 4Q avg 11.4% · 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 | 8.8% |
21.5%
12.7 pts better
|
16.3%
7.5 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 8.8% · 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 5.7% · Q2 7.8% · Q3 10.2% · Q4 8.5% · 4Q avg 8.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
0.9%
0.4 pts worse
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 0.0% · Q3 0.9% · Q4 0.0% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.8% |
2.6%
0.8 pts better
|
1.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 0.0% · Q3 2.2% · Q4 2.2% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 27.3% |
21.2%
6.1 pts worse
|
19.8%
7.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.2% · Q2 38.4% · Q3 23.8% · Q4 26.1% · 4Q avg 27.3% |
| Percentage of long-stay residents with pressure ulcers | 3.0% |
6.0%
3 pts better
|
5.1%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.4% · Q2 1.0% · Q3 4.8% · Q4 2.4% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 87.4% |
79.9%
7.5 pts better
|
81.7%
5.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 92.9% · Q2 88.3% · Q3 86.6% · Q4 73.6% · 4Q avg 87.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.2% |
13.2%
1 pts better
|
12.0%
0.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.2% · Observed 13.2% · Expected 12.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.5%
0.8 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.0% · Q3 0.0% · Q4 2.6% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 79.4% |
78.1%
1.3 pts better
|
79.7%
0.3 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 79.4% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.0% |
22.9%
2.9 pts better
|
23.9%
3.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 20.0% · Observed 23.7% · Expected 28.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-18 · Fire 2023-03-09
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Cycle 3
Health 2023-03-09 · Fire 2021-07-01
3 health deficiencies
Top issue: Administration (1 deficiency)
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
2024-07-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-09-29
D · Potential for more than minimal harm
2024-07-18
K781 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of portable space heaters.
Corrected 2024-09-29
D · Potential for more than minimal harm
2024-07-18
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2024-09-29
D · Potential for more than minimal harm
2023-03-09
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-05-19
D · Potential for more than minimal harm
2023-03-09
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-05-19
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-07
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-08-31
D · Potential for more than minimal harm
2025-08-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-08-31
D · Potential for more than minimal harm
2025-08-07
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-08-31
B · Minimal harm
2025-08-07
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 2025-08-31
D · Potential for more than minimal harm
2025-06-25
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 2025-05-26
B · Minimal harm
2024-09-16
F584 · Resident Rights Deficiencies
Health
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Corrected 2024-10-24
D · Potential for more than minimal harm
2024-07-18
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2024-09-16
D · Potential for more than minimal harm
2024-07-18
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-16
D · Potential for more than minimal harm
2024-07-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-09-16
D · Potential for more than minimal harm
2024-07-18
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 2024-09-16
D · Potential for more than minimal harm
2024-07-18
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 2024-09-16
D · Potential for more than minimal harm
2023-03-09
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-03-18
B · Minimal harm
2023-03-09
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 2023-03-25
B · Minimal harm
2023-03-09
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-03-25
Penalties and ownership
What sits behind the stars
Ownership
Mcneill, John
5% Or Greater Indirect Ownership Interest · Individual
Ronald B And Cynthia J Mcneill 2013 Irrv Tr
5% Or Greater Indirect Ownership Interest · Organization
Ayers, Tracy
Operational/Managerial Control · Individual
Calcutt, Joeseph V
Corporate Officer · Individual
Liberty Commons Nursing And Rehabilitation Center Of Wake County, LLC
5% Or Greater Direct Ownership Interest · Organization
Liberty Healthcare Management Inc
Operational/Managerial Control · Organization
Liberty Long Term Care LLC
5% Or Greater Direct Ownership Interest · Organization
Mcneill, John
5% Or Greater Direct Ownership Interest · Individual
Mcneill, John
Corporate Director · Individual
Mcneill, Robert
Corporate Director · Individual
Mcneill, Ronald
5% Or Greater Direct Ownership Interest · Individual
Mcneill, Ronald
Corporate Director · Individual
Miller, Robert
Corporate Director · Individual
Moore, Amanda
Operational/Managerial Control · Individual
Wilson, Jeffrey
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Sunnybrook Rehabilitation Center
Raleigh, NC
2-star overall rating with 2-star inspections with $72,855 in total fines with 2 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#2
Tower Nursing and Rehabilitation Center
Raleigh, NC
2-star overall rating with 2-star inspections with $15,593 in total fines with 7 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Raleigh Rehabilitation Center
Raleigh, NC
2-star overall rating with 3-star inspections with $77,760 in total fines with 3 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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