Cycle 1
Health 2024-12-19 · Fire 2024-12-19
6 health deficiencies
Top issue: Resident Rights (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fayetteville, NC
Highland House Rehabilitation and Healthcare
1-star overall rating with 3-star inspections with 6 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
1700 Pamalee Drive, Fayetteville, NC
(910) 488-2295
Overall
1 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
1 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
106
Certified beds
Average residents
86
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Liberty Senior Living
Operator or chain grouping
Approved since
1991-03-05
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
No
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.25
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.94
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
1.93
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.12
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.19
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
2.66
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.15
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.24
CMS adjusted RN staffing hours
Adjusted total hours
3.00
CMS adjusted total nurse staffing hours
Case-mix index
1.43
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
59%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
8,476
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
26.64
Composite VBP score used to determine payment impact.
Payment multiplier
0.9842
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.83
Baseline 23.30% · Performance 21.21% · Measure score 2.83 · Achievement 0 · Improvement 2.83
Healthcare-associated infections
5.32
Baseline 10.47% · Performance 7.28% · Measure score 5.32 · Achievement 1.85 · Improvement 5.32
Total nurse turnover
1.60
Performance 57.14% · Measure score 1.60 · Achievement 1.60 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
0.91
Baseline 3.72 hours · Performance 3.34 hours · Measure score 0.91 · Achievement 0.91 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.72% |
10.72%
About the same
|
No Different than the National Rate · Eligible stays 87 · Observed rate 12.64% · Lower 95% interval 7.82% |
| Discharge to community | 44.84% |
50.57%
5.7 pts worse
|
No Different than the National Rate · Eligible stays 83 · Observed rate 33.73% · Lower 95% interval 35.61% |
| Medicare spending per beneficiary | 0.96 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 91.18% |
95.27%
4.1 pts worse
|
Numerator 31 · Denominator 34 |
| Falls with major injury | 2.94% |
0.77%
2.2 pts worse
|
Numerator 1 · Denominator 34 |
| Discharge self-care score | 33.33% |
53.69%
20.4 pts worse
|
Numerator 7 · Denominator 21 |
| Discharge mobility score | 28.57% |
50.94%
22.4 pts worse
|
Numerator 6 · Denominator 21 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 34 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.28% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 51 · Observed rate 7.84% · Lower 95% interval 4.2% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 83 |
| Staff flu vaccination coverage | 0% |
42%
42 pts worse
|
Numerator 0 · Denominator 114 |
| Discharge function score | 28.57% |
56.45%
27.9 pts worse
|
Numerator 6 · Denominator 21 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| 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 | Not Available |
25.2%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 75.1% |
91.5%
16.4 pts worse
|
93.4%
18.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 78.3% · Q2 75.4% · Q3 75.4% · Q4 71.2% · 4Q avg 75.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 82.4% |
94.1%
11.7 pts worse
|
95.5%
13.1 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 82.4% |
| 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 1.4% · Q2 1.5% · Q3 1.6% · Q4 0.0% · 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 0.0% · Q3 0.0% · Q4 1.7% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 1.8% |
7.2%
5.4 pts better
|
5.4%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 1.8% · Q3 1.8% · Q4 1.8% · 4Q avg 1.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.7% |
21.6%
6.9 pts better
|
19.6%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 13.8% · Q3 12.7% · Q4 15.3% · 4Q avg 14.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.6% |
15.0%
9.6 pts worse
|
16.7%
7.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.9% · Q2 19.5% · Q3 27.3% · Q4 22.2% · 4Q avg 24.6% · 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 | 35.3% |
21.5%
13.8 pts worse
|
16.3%
19 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 35.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 25.9% |
16.8%
9.1 pts worse
|
14.9%
11 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.2% · Q2 35.6% · Q3 27.3% · Q4 26.0% · 4Q avg 25.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.9% |
0.9%
1 pts worse
|
1.0%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 1.2% · Q3 2.2% · Q4 1.0% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.8% |
2.6%
3.2 pts worse
|
1.7%
4.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 7.8% · Q3 6.6% · Q4 6.2% · 4Q avg 5.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.4% |
21.2%
0.2 pts worse
|
19.8%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.9% · Q2 19.8% · Q3 23.1% · Q4 15.0% · 4Q avg 21.4% |
| 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 6.4% · Q2 11.0% · Q3 5.6% · Q4 2.9% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 74.7% |
79.9%
5.2 pts worse
|
81.7%
7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 54.4% · Q2 69.1% · Q3 81.6% · Q4 84.8% · 4Q avg 74.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.2% |
13.2%
3 pts better
|
12.0%
1.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.2% · Observed 12.5% · Expected 13.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.9% |
1.5%
0.4 pts worse
|
1.6%
0.3 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 1.6% · Q3 1.3% · Q4 1.2% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 61.5% |
78.1%
16.6 pts worse
|
79.7%
18.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 61.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 34.6% |
22.9%
11.7 pts worse
|
23.9%
10.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 34.6% · Observed 43.8% · Expected 30.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-25 · Fire 2023-10-25
0 health deficiencies
No concentrated health issue counts in this cycle.
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-06-24 · Fire 2022-06-24
18 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-12-19
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-03-29
D · Potential for more than minimal harm
2024-12-19
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 2025-03-29
D · Potential for more than minimal harm
2024-12-19
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2025-03-29
D · Potential for more than minimal harm
2024-12-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-03-29
D · Potential for more than minimal harm
2024-12-19
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-03-29
D · Potential for more than minimal harm
2024-12-19
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 2025-03-29
D · Potential for more than minimal harm
2024-12-19
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-03-29
F · Potential for more than minimal harm
2023-10-25
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-12-15
F · Potential for more than minimal harm
2023-10-25
K915 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper power supply for life support equipment.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-10-25
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-12-15
F · Potential for more than minimal harm
2022-06-24
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-08-26
F · Potential for more than minimal harm
2022-06-24
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2022-08-26
F · Potential for more than minimal harm
2022-06-24
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-08-26
F · Potential for more than minimal harm
2022-06-24
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 2022-08-26
D · Potential for more than minimal harm
2022-06-24
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-08-26
D · Potential for more than minimal harm
2022-06-24
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-08-26
D · Potential for more than minimal harm
2022-06-24
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-08-26
D · Potential for more than minimal harm
2022-06-24
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-08-26
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-12-19
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-01-21
D · Potential for more than minimal harm
2024-12-19
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-01-21
D · Potential for more than minimal harm
2024-12-19
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-01-21
D · Potential for more than minimal harm
2024-12-19
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-01-21
D · Potential for more than minimal harm
2024-12-19
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-01-21
B · Minimal harm
2024-12-19
F567 · Resident Rights Deficiencies
Health
Honor the resident's right to manage his or her financial affairs.
Corrected 2025-01-22
E · Potential for more than minimal harm
2023-08-24
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-09-19
D · Potential for more than minimal harm
2023-08-24
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2023-09-19
D · Potential for more than minimal harm
2023-06-14
F808 · Nutrition and Dietary Deficiencies
Health
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Corrected 2023-06-30
E · Potential for more than minimal harm
2023-04-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-06-14
E · Potential for more than minimal harm
2023-04-26
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2023-06-14
E · Potential for more than minimal harm
2023-03-08
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 2023-04-26
D · Potential for more than minimal harm
2023-03-08
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2023-04-26
D · Potential for more than minimal harm
2023-03-08
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2023-04-26
D · Potential for more than minimal harm
2023-03-08
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-04-26
D · Potential for more than minimal harm
2023-03-08
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-06-14
D · Potential for more than minimal harm
2023-03-08
F887 · Infection Control Deficiencies
Health
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Corrected 2023-04-26
J · Immediate jeopardy
2022-06-24
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2022-01-05
J · Immediate jeopardy
2022-06-24
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2022-01-05
E · Potential for more than minimal harm
2022-06-24
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2022-07-22
D · Potential for more than minimal harm
2022-06-24
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-07-22
D · Potential for more than minimal harm
2022-06-24
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2022-07-22
D · Potential for more than minimal harm
2022-06-24
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-07-22
D · Potential for more than minimal harm
2022-06-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-07-22
Penalties and ownership
What sits behind the stars
Ownership
Liberty Long Term Care LLC
5% Or Greater Direct Ownership Interest · Organization
Calcutt, Joeseph V
Corporate Officer · Individual
Drake, Tonya
W-2 Managing Employee · 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
Purifoy, Penny
W-2 Managing Employee · Individual
Ronald B And Cynthia J Mcneill 2013 Irrv Tr
5% Or Greater Indirect Ownership Interest · Organization
Wilson, Jeffrey
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Woodlands Nursing & Rehabilitation Center
Fayetteville, NC
4-star overall rating with 4-star inspections with $4,709 in total fines with 2 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Haymount Rehabilitation & Nursing Center, Inc.
Fayetteville, NC
5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
#3
Whispering Pines Nursing & Rehab Center
Fayetteville, NC
5-star overall rating with 5-star inspections with $8,512 in total fines with 6 fire-safety deficiencies in the latest cycle
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