Cycle 1
Health 2025-11-25 · Fire 2024-10-09
1 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
5 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Weldon, NC
Liberty Commons Nursing and Rehabilitation Center
4-star overall rating with 4-star inspections with 1 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
101 Caroline Avenue, Weldon, NC
(252) 536-4817
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
50
Certified beds
Average residents
45
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Liberty Senior Living
Operator or chain grouping
Approved since
1989-09-25
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
0.65
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.78
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
1.76
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.19
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.43
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
2.79
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.50
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.14
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.70
CMS adjusted RN staffing hours
Adjusted total hours
3.45
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
44%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,627
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
29.20
Composite VBP score used to determine payment impact.
Payment multiplier
0.9853
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.40
Baseline 22.46% · Performance 20.88% · Measure score 2.40 · Achievement 1.19 · Improvement 2.40
Healthcare-associated infections
2.54
Baseline 6.17% · Performance 7.07% · Measure score 2.54 · Achievement 2.54 · Improvement 0
Total nurse turnover
5.39
Baseline 50.00% · Performance 41.67% · Measure score 5.39 · Achievement 5.39 · Improvement 2.81
Adjusted total nurse staffing
1.35
Baseline 3.75 hours · Performance 3.46 hours · Measure score 1.35 · Achievement 1.35 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.35% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 130 · Observed rate 11.54% · Lower 95% interval 8.03% |
| Discharge to community | 56.18% |
50.57%
5.6 pts better
|
No Different than the National Rate · Eligible stays 142 · Observed rate 51.41% · Lower 95% interval 49.42% |
| Medicare spending per beneficiary | 1.08 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 98.94% |
95.27%
3.7 pts better
|
Numerator 93 · Denominator 94 |
| Falls with major injury | 3.19% |
0.77%
2.4 pts worse
|
Numerator 3 · Denominator 94 |
| Discharge self-care score | 64.18% |
53.69%
10.5 pts better
|
Numerator 43 · Denominator 67 |
| Discharge mobility score | 61.19% |
50.94%
10.2 pts better
|
Numerator 41 · Denominator 67 |
| Pressure ulcers or injuries, new or worsened | 4.26% |
2.29%
2 pts worse
|
Numerator 4 · Denominator 94 · Adjusted rate 4.93% |
| Healthcare-associated infections requiring hospitalization | 7.07% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 87 · Observed rate 5.75% · Lower 95% interval 3.83% |
| Staff COVID-19 vaccination coverage | 4.69% |
8.2%
3.5 pts worse
|
Numerator 3 · Denominator 64 |
| Staff flu vaccination coverage | 6.86% |
42%
35.1 pts worse
|
Numerator 7 · Denominator 102 |
| Discharge function score | 58.21% |
56.45%
1.8 pts better
|
Numerator 39 · Denominator 67 |
| Transfer of health information to provider | 96.43% |
95.95%
0.5 pts better
|
Numerator 27 · Denominator 28 |
| Transfer of health information to patient | 93.88% |
96.28%
2.4 pts worse
|
Numerator 46 · Denominator 49 |
| Resident COVID-19 vaccinations up to date | 14% |
25.2%
11.2 pts worse
|
Numerator 7 · Denominator 50 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.3 |
1.8
0.5 pts worse
|
1.9
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 3.3 · Expected 2.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.5 |
1.8
0.7 pts worse
|
1.8
0.7 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 3.0 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.9% |
91.5%
6.4 pts better
|
93.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 97.1% · Q2 97.1% · Q3 97.4% · Q4 100.0% · 4Q avg 97.9% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.1%
5.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.2% |
3.6%
0.6 pts worse
|
3.3%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 2.9% · Q3 2.6% · Q4 5.6% · 4Q avg 4.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
4.8%
4.8 pts better
|
11.4%
11.4 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 who lose too much weight | 2.4% |
7.2%
4.8 pts better
|
5.4%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.3% · Q3 3.0% · Q4 3.1% · 4Q avg 2.4% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.8% |
21.6%
6.8 pts better
|
19.6%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 10.0% · Q3 17.6% · Q4 15.6% · 4Q avg 14.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.6% |
15.0%
0.6 pts worse
|
16.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 16.7% · Q3 12.9% · Q4 12.9% · 4Q avg 15.6% · 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 | 16.6% |
21.5%
4.9 pts better
|
16.3%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.9% |
16.8%
0.1 pts worse
|
14.9%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.6% · Q2 14.8% · Q3 16.7% · Q4 13.3% · 4Q avg 16.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
0.9%
About the same
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.7% · Q4 2.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 6.3% |
2.6%
3.7 pts worse
|
1.7%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 8.6% · Q3 5.3% · Q4 8.3% · 4Q avg 6.3% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 22.0% |
21.2%
0.8 pts worse
|
19.8%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.7% · Q2 23.1% · Q3 20.0% · Q4 18.5% · 4Q avg 22.0% |
| Percentage of long-stay residents with pressure ulcers | 7.4% |
6.0%
1.4 pts worse
|
5.1%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 10.3% · Q3 7.7% · Q4 5.1% · 4Q avg 7.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.6% |
79.9%
18.7 pts better
|
81.7%
16.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.5% · Q2 98.7% · Q3 100.0% · Q4 100.0% · 4Q avg 98.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 19.8% |
13.2%
6.6 pts worse
|
12.0%
7.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 19.8% · Observed 19.2% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.0% |
1.5%
0.5 pts better
|
1.6%
0.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.1% · Q2 1.8% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.8% |
78.1%
9.7 pts better
|
79.7%
8.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.8% |
22.9%
0.1 pts better
|
23.9%
1.1 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.8% · Observed 21.8% · Expected 22.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-09 · Fire 2023-06-15
2 health deficiencies
Top issue: Environmental (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-06-15 · Fire 2022-03-03
2 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-10-09
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 2024-12-10
D · Potential for more than minimal harm
2024-10-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-10-09
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-10-09
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-10
D · Potential for more than minimal harm
2024-10-09
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-12-10
F · Potential for more than minimal harm
2023-06-15
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-24
D · Potential for more than minimal harm
2023-06-15
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 2023-08-24
D · Potential for more than minimal harm
2023-06-15
K371 · Smoke Deficiencies
Fire Safety
Have properly sized and located compartments to protect residents from smoke.
Corrected 2023-08-24
D · Potential for more than minimal harm
2023-06-15
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-08-24
D · Potential for more than minimal harm
2023-06-15
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-08-24
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-25
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2025-12-19
F · Potential for more than minimal harm
2024-10-09
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2024-10-29
D · Potential for more than minimal harm
2024-10-09
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 2024-10-29
E · Potential for more than minimal harm
2023-06-15
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2023-06-30
D · Potential for more than minimal harm
2023-06-15
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-06-30
Penalties and ownership
What sits behind the stars
Ownership
Calcutt, Joeseph V
Corporate Officer · Individual
Liberty Commons Nursing And Rehabilitation Center Of Halifax County, L
5% Or Greater Direct Ownership Interest · Organization
Liberty Healthcare Management Inc
Operational/Managerial Control · Organization
Liberty Long Term Care LLC
5% Or Greater Direct Ownership Interest · Organization
Long Term Care Management Services LLC
Operational/Managerial Control · Organization
Mcneill, John
Corporate Director · Individual
Mcneill, Ronald
5% Or Greater Direct Ownership Interest · Individual
Mcneill, Ronald
Corporate Director · Individual
Miller, Robert
Corporate Director · Individual
Prather, Trina
Operational/Managerial Control · Individual
Purifoy, Penny
Corporate Director · Individual
Slade, Veronica
Operational/Managerial Control · Individual
Wilson, Jeffrey
Corporate Director · Individual
Wilson, Jeffrey
Corporate Officer · Individual
Nearby options
Other facilities in reach
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Signature Healthcare of Roanoke Rapids
Roanoke Rapids, NC
2-star overall rating with 2-star inspections with $9,110 in total fines with 13 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Northampton Nursing and Rehabilitation Center
Jackson, NC
3-star overall rating with 4-star inspections with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Emporia Rehabilitation And Healthcare Center
Emporia, VA
2-star overall rating with 2-star inspections with 19 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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