Cycle 1
Health 2026-01-08 · Fire 2024-09-27
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
2 fire-safety deficiencies
Top issue: Services (1 deficiency)
Burlington, NC
Liberty Commons Nursing & Rehabilitation Center of
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
791 Boone Station Drive, Burlington, NC
(336) 586-9850
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
122
Certified beds
Average residents
113
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Liberty Senior Living
Operator or chain grouping
Approved since
1999-10-06
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
0.23
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
1.10
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.79
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
4.11
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.32
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.70
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
0.09
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.25
CMS adjusted RN staffing hours
Adjusted total hours
4.44
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
86%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
62%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,516
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
23.43
Composite VBP score used to determine payment impact.
Payment multiplier
0.9832
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.98% · Performance 23.77% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
7.61
Baseline 9.56% · Performance 5.86% · Measure score 7.61 · Achievement 6.62 · Improvement 7.61
Total nurse turnover
1.14
Baseline 72.22% · Performance 64.47% · Measure score 1.14 · Achievement 0 · Improvement 1.14
Adjusted total nurse staffing
0.62
Baseline 3.13 hours · Performance 3.25 hours · Measure score 0.62 · Achievement 0.62 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.41% |
10.72%
1.3 pts better
|
No Different than the National Rate · Eligible stays 131 · Observed rate 5.34% · Lower 95% interval 7.07% |
| Discharge to community | 50.26% |
50.57%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 141 · Observed rate 47.52% · Lower 95% interval 43.68% |
| Medicare spending per beneficiary | 0.7 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 94.62% |
95.27%
0.6 pts worse
|
Numerator 88 · Denominator 93 |
| Falls with major injury | 1.08% |
0.77%
0.3 pts worse
|
Numerator 1 · Denominator 93 |
| Discharge self-care score | 32.86% |
53.69%
20.8 pts worse
|
Numerator 23 · Denominator 70 |
| Discharge mobility score | 62.86% |
50.94%
11.9 pts better
|
Numerator 44 · Denominator 70 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 93 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 5.86% |
7.12%
1.3 pts better
|
No Different than the National Rate · Eligible stays 88 · Observed rate 2.27% · Lower 95% interval 3.21% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 107 |
| Staff flu vaccination coverage | 16.52% |
42%
25.5 pts worse
|
Numerator 19 · Denominator 115 |
| Discharge function score | 48.57% |
56.45%
7.9 pts worse
|
Numerator 34 · Denominator 70 |
| Transfer of health information to provider | 98.46% |
95.95%
2.5 pts better
|
Numerator 64 · Denominator 65 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 53.66% |
25.2%
28.5 pts better
|
Numerator 22 · Denominator 41 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.5%
8.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 61.9% |
94.1%
32.2 pts worse
|
95.5%
33.6 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 61.9% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.3% |
3.6%
0.3 pts better
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 1.2% · Q3 3.6% · Q4 5.6% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.3% |
4.8%
4.5 pts better
|
11.4%
11.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% |
| Percentage of long-stay residents who lose too much weight | 9.1% |
7.2%
1.9 pts worse
|
5.4%
3.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 9.8% · Q3 11.3% · Q4 11.9% · 4Q avg 9.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 15.5% |
21.6%
6.1 pts better
|
19.6%
4.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 16.1% · Q3 12.5% · Q4 14.9% · 4Q avg 15.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 23.6% |
15.0%
8.6 pts worse
|
16.7%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.5% · Q2 21.2% · Q3 25.0% · Q4 23.4% · 4Q avg 23.6% · 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 | 27.6% |
21.5%
6.1 pts worse
|
16.3%
11.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 45.2% · Q2 22.4% · Q3 26.5% · Q4 14.0% · 4Q avg 27.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 19.8% |
16.8%
3 pts worse
|
14.9%
4.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.2% · Q2 16.9% · Q3 15.3% · Q4 15.2% · 4Q avg 19.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
0.9%
0.2 pts worse
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 3.5% · Q3 0.8% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.8% |
2.6%
0.8 pts better
|
1.7%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 0.0% · Q3 1.2% · Q4 3.3% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.7% |
21.2%
5.5 pts worse
|
19.8%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 33.8% · Q3 26.7% · Q4 27.9% · 4Q avg 26.7% |
| Percentage of long-stay residents with pressure ulcers | 6.2% |
6.0%
0.2 pts worse
|
5.1%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 7.0% · Q3 7.2% · Q4 7.3% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
79.9%
19.4 pts better
|
81.7%
17.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.8% · Q3 99.0% · Q4 99.5% · 4Q avg 99.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.1% |
13.2%
2.9 pts worse
|
12.0%
4.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.1% · Observed 15.3% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.6% |
1.5%
0.1 pts worse
|
1.6%
About the same
|
Short Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 3.1% · Q3 1.8% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 72.6% |
78.1%
5.5 pts worse
|
79.7%
7.1 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 72.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.5% |
22.9%
6.6 pts worse
|
23.9%
5.6 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.5% · Observed 27.1% · Expected 21.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-09-27 · Fire 2023-06-08
4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-06-08 · Fire 2021-10-14
0 health deficiencies
No concentrated health issue counts in this cycle.
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
2024-09-27
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-29
D · Potential for more than minimal harm
2024-09-27
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-11-29
D · Potential for more than minimal harm
2023-06-08
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-08-20
D · Potential for more than minimal harm
2023-06-08
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-20
D · Potential for more than minimal harm
2023-06-08
K362 · Smoke Deficiencies
Fire Safety
Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke.
Corrected 2023-08-20
D · Potential for more than minimal harm
2023-06-08
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-08-20
D · Potential for more than minimal harm
2023-06-08
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-08-20
D · Potential for more than minimal harm
2023-06-08
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 2023-08-20
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-01-08
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 2026-01-17
D · Potential for more than minimal harm
2026-01-08
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2025-03-28
D · Potential for more than minimal harm
2024-09-27
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2024-10-10
D · Potential for more than minimal harm
2024-09-27
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-10-10
B · Minimal harm
2024-09-27
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-10-10
B · Minimal harm
2024-09-27
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-10-10
Penalties and ownership
What sits behind the stars
Ownership
Long Term Care Management Services LLC
5% Or Greater Direct Ownership Interest · Organization
Calcutt, Joeseph V
Operational/Managerial Control · Individual
Hamric, Anthony
Operational/Managerial Control · Individual
Liberty Commons Nursing And Rehabilitation Center Of Alamance County,
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
5% Or Greater Indirect Ownership Interest · Individual
Mcneill, John
Operational/Managerial Control · Individual
Mcneill, John
Corporate Director · Individual
Mcneill, Ronald
5% Or Greater Indirect Ownership Interest · Individual
Mcneill, Ronald
Operational/Managerial Control · Individual
Newman, James
W-2 Managing Employee · Individual
Purifoy, Penny
Operational/Managerial Control · Individual
Wilson, Jeffrey
Operational/Managerial Control · Individual
Wilson, Jeffrey
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Twin Lakes Community
Burlington, NC
5-star overall rating with 4-star inspections with $6,152 in total fines with 2 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Edgewood Place at the Village at Brookwood
Burlington, NC
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
White Oak Manor - Burlington
Burlington, NC
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $148,522 in total fines with 9 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
Jump out