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
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
0.60
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.44
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.64
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.67
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.04
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.31
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.30
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.58
CMS adjusted RN staffing hours
Adjusted total hours
3.59
CMS adjusted total nurse staffing hours
Case-mix index
1.40
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,348
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
44.80
Composite VBP score used to determine payment impact.
Payment multiplier
0.9979
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.04
Baseline 20.31% · Performance 19.09% · Measure score 5.04 · Achievement 5.04 · Improvement 3.21
Healthcare-associated infections
6.91
Baseline 6.58% · Performance 5.77% · Measure score 6.91 · Achievement 6.91 · Improvement 4.59
Total nurse turnover
5.97
Baseline 53.33% · Performance 39.29% · Measure score 5.97 · Achievement 5.97 · Improvement 4.43
Adjusted total nurse staffing
0
Baseline 3 hours · Performance 3.01 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.55% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 84 · Observed rate 11.9% · Lower 95% interval 7.38% |
| Discharge to community | 56.12% |
50.57%
5.5 pts better
|
No Different than the National Rate · Eligible stays 78 · Observed rate 47.44% · Lower 95% interval 45.49% |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 98.51% |
95.27%
3.2 pts better
|
Numerator 66 · Denominator 67 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 67 |
| Discharge self-care score | 62.75% |
53.69%
9.1 pts better
|
Numerator 32 · Denominator 51 |
| Discharge mobility score | 43.14% |
50.94%
7.8 pts worse
|
Numerator 22 · Denominator 51 |
| Pressure ulcers or injuries, new or worsened | 1.49% |
2.29%
0.8 pts better
|
Numerator 1 · Denominator 67 · Adjusted rate 1.3% |
| Healthcare-associated infections requiring hospitalization | 5.77% |
7.12%
1.4 pts better
|
No Different than the National Rate · Eligible stays 65 · Observed rate 3.08% · Lower 95% interval 3.6% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 107 |
| Staff flu vaccination coverage | 45.45% |
42%
3.5 pts better
|
Numerator 50 · Denominator 110 |
| Discharge function score | 50.98% |
56.45%
5.5 pts worse
|
Numerator 26 · Denominator 51 |
| Transfer of health information to provider | 3.33% |
95.95%
92.6 pts worse
|
Numerator 1 · Denominator 30 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 35 |
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 · Q1 100.0% · Q2 98.6% · Q3 100.0% · Q4 100.0% · 4Q avg 99.6% |
| 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 · 4Q avg 98.7% |
| 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 · Q1 0.0% · Q2 1.4% · Q3 1.5% · Q4 1.5% · 4Q avg 1.1% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 1.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% |
| 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 · Q1 13.0% · Q2 11.1% · Q3 4.0% · Q4 3.6% · 4Q avg 7.9% |
| 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 · Q1 22.2% · Q2 16.4% · Q3 12.0% · Q4 10.7% · 4Q avg 15.3% |
| 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 · Q1 15.2% · Q2 6.5% · Q3 4.5% · Q4 4.3% · 4Q avg 7.7% · 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 | 29.0% |
21.5%
7.5 pts worse
|
16.3%
12.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 29.0% · Used in QM five-star |
| 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 · Q1 21.4% · Q2 21.7% · Q3 13.3% · Q4 14.8% · 4Q avg 17.6% · Used in QM five-star |
| 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 · Q1 4.5% · Q2 5.1% · Q3 2.7% · Q4 1.0% · 4Q avg 3.3% · Used in QM five-star |
| 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 · Q1 2.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| 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 · Q1 21.1% · Q2 15.8% · Q3 21.1% · Q4 22.2% · 4Q avg 20.1% |
| 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 · Q1 5.3% · Q2 8.0% · Q3 7.0% · Q4 5.8% · 4Q avg 6.5% · Used in QM five-star |
| 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 · Q1 96.1% · Q2 97.4% · Q3 98.5% · Q4 96.6% · 4Q avg 97.2% |
| 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 · Adjusted 21.5% · Observed 22.7% · Expected 11.8% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| 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 · 4Q avg 95.7% |
| 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 · Adjusted 20.9% · Observed 21.2% · Expected 24.2% · Used in QM five-star |
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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