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

Compare this facility

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

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

Staffing

Hours and turnover

RN hours / resident day

0.25

Registered nurse staffing

LPN hours / resident day

0.94

Licensed practical nurse staffing

Aide hours / resident day

1.93

Nurse aide staffing

Weekend hours

2.66

Weekend nurse staffing

RN turnover

50%

Annual RN turnover

Total nurse turnover

59%

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	75.1%	91.5% 16.4 pts worse	93.4% 18.3 pts worse	Long Stay · 2024Q4-2025Q3
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
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	1.8%	7.2% 5.4 pts better	5.4% 3.6 pts better	Long Stay · 2024Q4-2025Q3
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
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
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	35.3%	21.5% 13.8 pts worse	16.3% 19 pts worse	Long Stay · 2024Q4-2025Q3
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
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
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
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
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	74.7%	79.9% 5.2 pts worse	81.7% 7 pts worse	Short Stay · 2024Q4-2025Q3
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
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
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
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

Survey summary

Recent inspection cycles

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)

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

100% 21 facilities 2022-09-30

Calcutt, Joeseph V

Corporate Officer · Individual

0% 34 facilities 2022-10-01

Drake, Tonya

W-2 Managing Employee · Individual

0% 1 facilities 2023-04-23

John A Mcneill Jr 2012 Irrv Tr

5% Or Greater Indirect Ownership Interest · Organization

0% 13 facilities 2022-09-30

Liberty Healthcare Group LLC

5% Or Greater Indirect Ownership Interest · Organization

0% 14 facilities 2022-09-30

Mcneill, John

5% Or Greater Indirect Ownership Interest · Individual

0% 32 facilities 2022-09-30

Mcneill, Ronald

5% Or Greater Indirect Ownership Interest · Individual

0% 32 facilities 2022-09-30

Purifoy, Penny

W-2 Managing Employee · Individual

0% 13 facilities 2022-10-01

Ronald B And Cynthia J Mcneill 2013 Irrv Tr

5% Or Greater Indirect Ownership Interest · Organization

0% 15 facilities 2022-09-30

Wilson, Jeffrey

Corporate Officer · Individual

0% 36 facilities 2022-10-01

Nearby options

Other facilities in reach

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

Overall: 4 / 5
Health: 4 / 5
Staffing: 3 / 5
Fines: $4,709