Cycle 1
Health 2025-09-16 · Fire 2024-09-26
4 health deficiencies
Top issue: Environmental (1 deficiency)
9 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Elizabethtown, NC
Elizabethtown Healthcare & Rehab Center
3-star overall rating with 3-star inspections with $13,520 in total fines with 4 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
208 Mercer Mill Road, Elizabethtown, NC
(910) 862-8181
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
94
Certified beds
Average residents
83
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Liberty Senior Living
Operator or chain grouping
Approved since
1981-10-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.60
Registered nurse staffing
LPN hours / resident day
0.44
Licensed practical nurse staffing
Aide hours / resident day
2.64
Nurse aide staffing
Weekend hours
3.31
Weekend nurse staffing
RN turnover
33%
Annual RN turnover
Total nurse turnover
49%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.6% |
91.5%
8.1 pts better
|
93.4%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.7% |
94.1%
4.6 pts better
|
95.5%
3.2 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.1% |
3.6%
2.5 pts better
|
3.3%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
4.8%
4.4 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 7.9% |
7.2%
0.7 pts worse
|
5.4%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.3% |
21.6%
6.3 pts better
|
19.6%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 7.7% |
15.0%
7.3 pts better
|
16.7%
9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 29.0% |
21.5%
7.5 pts worse
|
16.3%
12.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 17.6% |
16.8%
0.8 pts worse
|
14.9%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 3.3% |
0.9%
2.4 pts worse
|
1.0%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
2.6%
1.9 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 20.1% |
21.2%
1.1 pts better
|
19.8%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 6.5% |
6.0%
0.5 pts worse
|
5.1%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.2% |
79.9%
17.3 pts better
|
81.7%
15.5 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 21.5% |
13.2%
8.3 pts worse
|
12.0%
9.5 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.7% |
78.1%
17.6 pts better
|
79.7%
16 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 20.9% |
22.9%
2 pts better
|
23.9%
3 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-26 · Fire 2023-06-22
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
1 fire-safety deficiencies
Top issue: Services (1 deficiency)
Cycle 3
Health 2023-06-22 · Fire 2022-03-03
0 health deficiencies
No concentrated health issue counts in this cycle.
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-09-26
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-07
E · Potential for more than minimal harm
2024-09-26
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-12-07
E · Potential for more than minimal harm
2024-09-26
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-07
D · Potential for more than minimal harm
2024-09-26
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 2024-12-07
D · Potential for more than minimal harm
2024-09-26
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2024-12-07
D · Potential for more than minimal harm
2024-09-26
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-12-07
D · Potential for more than minimal harm
2024-09-26
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-12-07
D · Potential for more than minimal harm
2024-09-26
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-12-07
D · Potential for more than minimal harm
2024-09-26
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-12-07
F · Potential for more than minimal harm
2023-06-22
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-08-29
F · Potential for more than minimal harm
2022-03-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-03-30
Inspection history
Recent health citations
G · Actual harm
2025-09-16
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 2025-08-09
D · Potential for more than minimal harm
2025-09-16
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 2025-09-17
D · Potential for more than minimal harm
2025-09-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-17
D · Potential for more than minimal harm
2025-09-16
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-09-17
D · Potential for more than minimal harm
2024-09-26
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-09-13
B · Minimal harm
2024-09-26
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 2024-10-26
Penalties and ownership
What sits behind the stars
$13,520
2025-09-16
Fine
Fine · fine $13,520
Fine
Ownership
Liberty Long Term Care LLC
5% Or Greater Direct Ownership Interest · Organization
Barrow, Lori
Operational/Managerial Control · Individual
Calcutt, Joeseph V
Operational/Managerial Control · Individual
Caquias Gonzalez, Eileen
Operational/Managerial Control · Individual
John A Mcneill Jr 2012 Irrv Tr
5% Or Greater Indirect Ownership Interest · Organization
Liberty Healthcare Group LLC
5% Or Greater Indirect Ownership Interest · Organization
Mcneill, John
5% Or Greater Indirect Ownership Interest · Individual
Mcneill, Ronald
5% Or Greater Indirect Ownership Interest · Individual
Miller, Robert
Operational/Managerial Control · Individual
Ronald B And Cynthia J Mcneill 2013 Irrv Tr
5% Or Greater Indirect Ownership Interest · Organization
Wilson, Jeffrey
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Bladen East Health And Rehab
Elizabethtown, NC
2-star overall rating with 4-star inspections with $15,811 in total fines with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Liberty Commons Nursing and Rehabilitation Center
Whiteville, NC
1-star overall rating with 1-star inspections with $135,234 in total fines with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Shoreland Health Care and Retirement Center Inc
Whiteville, NC
4-star overall rating with 5-star inspections with $5,077 in total fines with 1 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
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