Cycle 1
Health 2025-11-19 · Fire 2024-09-11
5 health deficiencies
Top issue: Nutrition and Dietary (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Salisbury, NC
Liberty Commons Nsg and Rehab Ctr of Rowan County
3-star overall rating with 3-star inspections with $14,521 in total fines with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
4412 South Main Street, Salisbury, NC
(704) 637-3040
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
90
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
2000-05-31
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
0.43
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.92
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
3.27
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.34
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
2.99
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.19
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
3.70
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
40%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,280
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
6.94
Composite VBP score used to determine payment impact.
Payment multiplier
0.9806
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.01
Baseline 19.81% · Performance 20.50% · Measure score 2.01 · Achievement 2.01 · Improvement 0
Healthcare-associated infections
0
Baseline 7.72% · Performance 8.24% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0
Baseline 32.69% · Performance 64.06% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0.76
Baseline 2.46 hours · Performance 2.88 hours · Measure score 0.76 · Achievement 0 · Improvement 0.76
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.47% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 138 · Observed rate 7.25% · Lower 95% interval 6.72% |
| Discharge to community | 54.94% |
50.57%
4.4 pts better
|
No Different than the National Rate · Eligible stays 135 · Observed rate 50.37% · Lower 95% interval 46.11% |
| Medicare spending per beneficiary | 0.97 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 59 · Denominator 59 |
| Falls with major injury | 1.69% |
0.77%
0.9 pts worse
|
Numerator 1 · Denominator 59 |
| Discharge self-care score | 60.47% |
53.69%
6.8 pts better
|
Numerator 26 · Denominator 43 |
| Discharge mobility score | 55.81% |
50.94%
4.9 pts better
|
Numerator 24 · Denominator 43 |
| Pressure ulcers or injuries, new or worsened | 1.69% |
2.29%
0.6 pts better
|
Numerator 1 · Denominator 59 · Adjusted rate 1.74% |
| Healthcare-associated infections requiring hospitalization | 8.24% |
7.12%
1.1 pts worse
|
No Different than the National Rate · Eligible stays 72 · Observed rate 9.72% · Lower 95% interval 4.99% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 94 |
| Staff flu vaccination coverage | 21.28% |
42%
20.7 pts worse
|
Numerator 20 · Denominator 94 |
| Discharge function score | 53.49% |
56.45%
3 pts worse
|
Numerator 23 · Denominator 43 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 22 · Denominator 22 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 28 · Denominator 28 |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 17 · 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 | 98.9% |
91.5%
7.4 pts better
|
93.4%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 97.2% · Q4 98.6% · 4Q avg 98.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.3% |
94.1%
3.2 pts better
|
95.5%
1.8 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.2% |
3.6%
2.6 pts worse
|
3.3%
2.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 6.1% · Q3 6.9% · Q4 7.0% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.0% |
4.8%
2.8 pts better
|
11.4%
9.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 1.6% · Q3 3.2% · Q4 0.0% · 4Q avg 2.0% |
| Percentage of long-stay residents who lose too much weight | 3.6% |
7.2%
3.6 pts better
|
5.4%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.8% · Q2 3.7% · Q3 3.5% · Q4 1.7% · 4Q avg 3.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 38.5% |
21.6%
16.9 pts worse
|
19.6%
18.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.6% · Q2 37.0% · Q3 42.1% · Q4 39.7% · 4Q avg 38.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 4.0% |
15.0%
11 pts better
|
16.7%
12.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 2.1% · Q3 3.8% · Q4 5.9% · 4Q avg 4.0% · 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 | 34.2% |
21.5%
12.7 pts worse
|
16.3%
17.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 42.9% · Q4 26.8% · 4Q avg 34.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.7% |
16.8%
4.9 pts worse
|
14.9%
6.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.6% · Q2 21.2% · Q3 26.4% · Q4 17.6% · 4Q avg 21.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.4% |
0.9%
0.5 pts worse
|
1.0%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.1% · Q3 2.2% · Q4 1.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.9% |
2.6%
0.3 pts worse
|
1.7%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 3.0% · Q3 2.8% · Q4 0.0% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.9% |
21.2%
3.3 pts better
|
19.8%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 21.3% · Q2 16.9% · Q3 12.9% · Q4 20.7% · 4Q avg 17.9% |
| Percentage of long-stay residents with pressure ulcers | 6.0% |
6.0%
About the same
|
5.1%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 6.7% · Q3 7.4% · Q4 2.8% · 4Q avg 6.0% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 91.1% |
79.9%
11.2 pts better
|
81.7%
9.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 93.5% · Q2 93.5% · Q3 89.2% · Q4 87.6% · 4Q avg 91.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.2% |
13.2%
4 pts better
|
12.0%
2.8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.2% · Observed 8.5% · Expected 10.3% · 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 | 86.1% |
78.1%
8 pts better
|
79.7%
6.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 86.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.6% |
22.9%
0.7 pts worse
|
23.9%
0.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.6% · Observed 23.4% · Expected 23.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-11 · Fire 2023-12-15
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2023-12-15 · Fire 2022-05-12
11 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-09-11
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-08
D · Potential for more than minimal harm
2024-09-11
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-11-08
D · Potential for more than minimal harm
2023-12-15
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 2024-02-02
D · Potential for more than minimal harm
2023-12-15
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-02-02
D · Potential for more than minimal harm
2022-05-12
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-06-27
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-11-19
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 2025-11-20
D · Potential for more than minimal harm
2025-11-19
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2025-11-20
D · Potential for more than minimal harm
2025-11-19
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 2025-11-20
D · Potential for more than minimal harm
2025-11-19
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2025-11-20
D · Potential for more than minimal harm
2025-11-19
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2025-11-20
E · Potential for more than minimal harm
2024-09-11
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 2024-10-02
D · Potential for more than minimal harm
2024-09-11
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2024-10-02
D · Potential for more than minimal harm
2024-09-11
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-10-02
F · Potential for more than minimal harm
2023-12-15
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 2023-11-11
E · Potential for more than minimal harm
2023-12-15
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-01-05
E · Potential for more than minimal harm
2023-12-15
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-01-05
E · Potential for more than minimal harm
2023-12-15
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 2024-01-05
E · Potential for more than minimal harm
2023-12-15
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-01-05
D · Potential for more than minimal harm
2023-12-15
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-01-05
B · Minimal harm
2023-12-15
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-12-02
B · Minimal harm
2023-12-15
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2023-12-02
B · Minimal harm
2023-12-15
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-12-02
J · Immediate jeopardy
2023-04-28
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 2023-04-05
D · Potential for more than minimal harm
2023-04-28
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-05-02
Penalties and ownership
What sits behind the stars
$14,521
2023-04-28
Fine
Fine · fine $14,521
Fine
Ownership
Bork, Matthew
Operational/Managerial Control · Individual
Calcutt, Joeseph V
Corporate Officer · Individual
Hamric, Anthony
Operational/Managerial Control · Individual
Liberty Commons Nursing And Rehabilitation Center Of Rowan County, LLC
5% Or Greater Direct Ownership Interest · Organization
Liberty Healthcare Group LLC
5% Or Greater Direct Ownership Interest · Organization
Liberty Healthcare Group LLC
Operational/Managerial Control · 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, Ronald
5% Or Greater Direct Ownership Interest · Individual
Mcneill, Ronald
Corporate Director · Individual
Miller, Robert
Corporate Director · Individual
Wilson, Jeffrey
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Trinity Oaks
Salisbury, NC
4-star overall rating with 3-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Piedmont Health & Rehab Center
Salisbury, NC
3-star overall rating with 3-star inspections with $8,512 in total fines with 5 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
The Laurels of Salisbury
Salisbury, NC
2-star overall rating with 2-star inspections with $45,756 in total fines with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
Jump out