Benson, NC

Liberty Commons Nursing & Rehabilitation Center of

2-star overall rating with 2-star inspections with $43,231 in total fines with 7 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle

2315 Highway 242 North, Benson, NC

(919) 207-1717

Compare this facility

Overall

2 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

2 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

100

Certified beds

Average residents

97

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Liberty Senior Living

Operator or chain grouping

Approved since

2002-09-25

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

0.52

Registered nurse staffing · state 0.59 · national 0.68

LPN hours / resident day

0.99

Licensed practical nurse staffing · state 0.87 · national 0.87

Aide hours / resident day

1.98

Nurse aide staffing · state 2.33 · national 2.35

Total nurse hours

3.49

All reported nurse hours · state 3.78 · national 3.89

Licensed hours

1.51

RN + LPN hours · state 1.45 · national 1.54

Weekend hours

3.25

Weekend nurse staffing · state 3.34 · national 3.43

Weekend RN hours

0.30

Weekend registered nurse coverage · state 0.38 · national 0.47

Physical therapist

0.10

Reported PT staffing · state 0.09 · national 0.07

Adjusted RN hours

0.47

CMS adjusted RN staffing hours

Adjusted total hours

3.14

CMS adjusted total nurse staffing hours

Case-mix index

1.52

Higher values indicate more complex resident acuity

RN turnover

46%

Annual RN turnover · state 48% · national 45%

Total nurse turnover

52%

Annual nurse turnover · state 50% · national 46%

SNF VBP

Value-based purchasing

Program rank

9,774

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

22.58

Composite VBP score used to determine payment impact.

Payment multiplier

0.9829

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

2.69

Baseline 21.87% · Performance 20.33% · Measure score 2.69 · Achievement 2.39 · Improvement 2.69

Healthcare-associated infections

6.35

Baseline 8.41% · Performance 6.07% · Measure score 6.35 · Achievement 5.90 · Improvement 6.35

Total nurse turnover

0

Baseline 71.31% · Performance 70.31% · Measure score 0 · Achievement 0 · Improvement 0

Adjusted total nurse staffing

0

Baseline 3.58 hours · Performance 3.13 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure Facility National Note
Potentially preventable 30-day readmission 10.93%
10.72%
0.2 pts worse
No Different than the National Rate · Eligible stays 237 · Observed rate 11.81% · Lower 95% interval 7.26%
Discharge to community 56.47%
50.57%
5.9 pts better
Better than the National Rate · Eligible stays 236 · Observed rate 50.42% · Lower 95% interval 50.95%
Medicare spending per beneficiary 0.98
1.02
About the same
Drug regimen review with follow-up 98.73%
95.27%
3.5 pts better
Numerator 155 · Denominator 157
Falls with major injury 0.64%
0.77%
0.1 pts better
Numerator 1 · Denominator 157
Discharge self-care score 51.69%
53.69%
2 pts worse
Numerator 61 · Denominator 118
Discharge mobility score 53.39%
50.94%
2.5 pts better
Numerator 63 · Denominator 118
Pressure ulcers or injuries, new or worsened 5.1%
2.29%
2.8 pts worse
Numerator 8 · Denominator 157 · Adjusted rate 5.65%
Healthcare-associated infections requiring hospitalization 6.07%
7.12%
1 pts better
No Different than the National Rate · Eligible stays 145 · Observed rate 4.83% · Lower 95% interval 3.65%
Staff COVID-19 vaccination coverage 11.97%
8.2%
3.8 pts better
Numerator 14 · Denominator 117
Staff flu vaccination coverage 7.46%
42%
34.5 pts worse
Numerator 17 · Denominator 228
Discharge function score 59.32%
56.45%
2.9 pts better
Numerator 70 · Denominator 118
Transfer of health information to provider 97.5%
95.95%
1.5 pts better
Numerator 117 · Denominator 120
Transfer of health information to patient 100%
96.28%
3.7 pts better
Numerator 22 · Denominator 22
Resident COVID-19 vaccinations up to date 0%
25.2%
25.2 pts worse
Numerator 0 · Denominator 85

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 96.1%
94.1%
2 pts better
95.5%
0.6 pts better
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.1%
Percentage of long-stay residents experiencing one or more falls with major injury 4.5%
3.6%
0.9 pts worse
3.3%
1.2 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 4.2% · Q3 5.6% · Q4 5.3% · 4Q avg 4.5% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms 56.7%
4.8%
51.9 pts worse
11.4%
45.3 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 64.7% · Q2 72.6% · Q3 47.8% · Q4 43.5% · 4Q avg 56.7%
Percentage of long-stay residents who lose too much weight 11.1%
7.2%
3.9 pts worse
5.4%
5.7 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 22.2% · Q4 19.7% · 4Q avg 11.1%
Percentage of long-stay residents who received an antianxiety or hypnotic medication 14.6%
21.6%
7 pts better
19.6%
5 pts better
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 14.8% · Q3 15.9% · Q4 14.5% · 4Q avg 14.6%
Percentage of long-stay residents who received an antipsychotic medication 12.1%
15.0%
2.9 pts better
16.7%
4.6 pts better
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 9.8% · Q3 14.3% · Q4 7.5% · 4Q avg 12.1% · 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 24.8%
21.5%
3.3 pts worse
16.3%
8.5 pts worse
Long Stay · 2024Q4-2025Q3 · 4Q avg 24.8% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased 5.4%
16.8%
11.4 pts better
14.9%
9.5 pts better
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 3.6% · Q3 3.4% · Q4 7.1% · 4Q avg 5.4% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder 1.7%
0.9%
0.8 pts worse
1.0%
0.7 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 0.0% · Q3 1.9% · Q4 1.5% · 4Q avg 1.7% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection 3.1%
2.6%
0.5 pts worse
1.7%
1.4 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 4.2% · Q3 2.8% · Q4 0.0% · 4Q avg 3.1% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 27.3%
21.2%
6.1 pts worse
19.8%
7.5 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 28.8% · Q2 28.3% · Q3 19.4% · Q4 33.0% · 4Q avg 27.3%
Percentage of long-stay residents with pressure ulcers 7.5%
6.0%
1.5 pts worse
5.1%
2.4 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 5.8% · Q3 9.8% · Q4 7.3% · 4Q avg 7.5% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 99.9%
79.9%
20 pts better
81.7%
18.2 pts better
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 99.4% · 4Q avg 99.9%
Percentage of short-stay residents who had an outpatient emergency department visit 13.9%
13.2%
0.7 pts worse
12.0%
1.9 pts worse
Short Stay · 20240701-20250630 · Adjusted 13.9% · Observed 14.3% · Expected 11.5% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication 1.1%
1.5%
0.4 pts better
1.6%
0.5 pts better
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.7% · Q3 2.2% · Q4 1.8% · 4Q avg 1.1% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 97.2%
78.1%
19.1 pts better
79.7%
17.5 pts better
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.2%
Percentage of short-stay residents who were rehospitalized after a nursing home admission 24.9%
22.9%
2 pts worse
23.9%
1 pts worse
Short Stay · 20240701-20250630 · Adjusted 24.9% · Observed 25.0% · Expected 23.9% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-11-20 · Fire 2024-07-12

7 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

9 fire-safety deficiencies

Top issue: Smoke (5 deficiencies)

Cycle 2 Health 2024-07-12 · Fire 2023-04-21

9 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

5 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 3 Health 2023-04-21 · Fire 2022-02-25

22 health deficiencies

Top issue: Pharmacy Service (5 deficiencies)

0 fire-safety deficiencies

No concentrated fire-safety issue counts in this cycle.

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2024-07-12

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2024-08-12

F · Potential for more than minimal harm 2024-07-12

K352 · Smoke Deficiencies

Fire Safety

Properly install and monitor supervisory attachments on automatic sprinkler systems.

Corrected 2024-10-06

F · Potential for more than minimal harm 2024-07-12

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-10-06

F · Potential for more than minimal harm 2024-07-12

K916 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have a battery powered remote alarm panel in a location accessible by operating personnel.

Corrected 2024-10-06

D · Potential for more than minimal harm 2024-07-12

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2024-10-06

D · Potential for more than minimal harm 2024-07-12

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2024-10-06

D · Potential for more than minimal harm 2024-07-12

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2024-10-06

D · Potential for more than minimal harm 2024-07-12

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2024-10-06

D · Potential for more than minimal harm 2024-07-12

K511 · Services Deficiencies

Fire Safety

Have properly installed electrical wiring and gas equipment.

Corrected 2024-10-06

E · Potential for more than minimal harm 2023-04-21

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2023-08-15

E · Potential for more than minimal harm 2023-04-21

K352 · Smoke Deficiencies

Fire Safety

Properly install and monitor supervisory attachments on automatic sprinkler systems.

Corrected 2023-08-15

D · Potential for more than minimal harm 2023-04-21

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 2023-08-15

D · Potential for more than minimal harm 2023-04-21

K372 · Smoke Deficiencies

Fire Safety

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Corrected 2023-08-15

D · Potential for more than minimal harm 2023-04-21

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2023-08-15

Inspection history

Recent health citations

E · Potential for more than minimal harm 2025-11-20

F565 · Resident Rights Deficiencies

Health

Honor the resident's right to organize and participate in resident/family groups in the facility.

Corrected 2025-12-19

D · Potential for more than minimal harm 2025-11-20

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2025-12-19

D · Potential for more than minimal harm 2025-11-20

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 2025-12-19

D · Potential for more than minimal harm 2025-11-20

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-12-19

D · Potential for more than minimal harm 2025-11-20

F694 · Quality of Life and Care Deficiencies

Health

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Corrected 2025-12-19

D · Potential for more than minimal harm 2025-11-20

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2025-12-19

B · Minimal harm 2025-11-20

F628 · Resident Rights Deficiencies

Health

Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Corrected 2025-12-19

D · Potential for more than minimal harm 2024-07-12

F645 · Resident Assessment and Care Planning Deficiencies

Health

PASARR screening for Mental disorders or Intellectual Disabilities

Corrected 2024-08-12

D · Potential for more than minimal harm 2024-07-12

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 2024-08-12

D · Potential for more than minimal harm 2024-07-12

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-08-12

D · Potential for more than minimal harm 2024-07-12

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2024-08-12

D · Potential for more than minimal harm 2024-07-12

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2024-08-12

D · Potential for more than minimal harm 2024-07-12

F758 · Pharmacy Service Deficiencies

Health

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected 2024-08-12

E · Potential for more than minimal harm 2024-04-25

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 2024-05-10

E · Potential for more than minimal harm 2024-04-25

F867 · Administration Deficiencies

Health

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected 2024-05-10

D · Potential for more than minimal harm 2024-04-25

F776 · Administration Deficiencies

Health

Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.

Corrected 2024-03-19

J · Immediate jeopardy 2023-12-08

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 2023-12-21

J · Immediate jeopardy 2023-12-08

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2023-12-21

E · Potential for more than minimal harm 2023-12-08

F944 · Administration Deficiencies

Health

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Corrected 2023-12-21

D · Potential for more than minimal harm 2023-12-08

F557 · Resident Rights Deficiencies

Health

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

Corrected 2023-11-03

D · Potential for more than minimal harm 2023-12-08

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2023-12-21

D · Potential for more than minimal harm 2023-12-08

F867 · Administration Deficiencies

Health

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected 2023-12-21

J · Immediate jeopardy 2023-06-02

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 2023-05-26

G · Actual harm 2023-04-21

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2022-10-24

F · Potential for more than minimal harm 2023-04-21

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 2023-06-06

F · Potential for more than minimal harm 2023-04-21

F867 · Administration Deficiencies

Health

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Corrected 2023-06-06

F · Potential for more than minimal harm 2023-04-21

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-06-06

E · Potential for more than minimal harm 2023-04-21

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2023-06-06

E · Potential for more than minimal harm 2023-04-21

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 2023-06-06

E · Potential for more than minimal harm 2023-04-21

F814 · Nutrition and Dietary Deficiencies

Health

Dispose of garbage and refuse properly.

Corrected 2023-06-06

D · Potential for more than minimal harm 2023-04-21

F638 · Resident Assessment and Care Planning Deficiencies

Health

Assure that each resident’s assessment is updated at least once every 3 months.

Corrected 2023-06-06

D · Potential for more than minimal harm 2023-04-21

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 2023-06-06

D · Potential for more than minimal harm 2023-04-21

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2023-06-06

D · Potential for more than minimal harm 2023-04-21

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 2023-06-06

D · Potential for more than minimal harm 2023-04-21

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2023-06-06

D · Potential for more than minimal harm 2023-04-21

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2023-06-06

D · Potential for more than minimal harm 2023-04-21

F758 · Pharmacy Service Deficiencies

Health

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected 2023-06-06

D · Potential for more than minimal harm 2023-04-21

F806 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Corrected 2023-06-06

Penalties and ownership

What sits behind the stars

$7,796 2023-12-08

Fine

Fine · fine $7,796

Fine

$7,797 2023-12-08

Fine

Fine · fine $7,797

Fine

$13,117 2023-04-21

Fine

Fine · fine $13,117

Fine

$14,521 2023-04-21

Fine

Fine · fine $14,521

Fine

$0 2023-04-21

Payment Denial

Payment Denial · denial start 2023-05-23 · 14 days

14 day denial

Ownership

Calcutt, Joeseph V

Corporate Officer · Individual

0% 34 facilities 2025-04-01
Hogue, Janet

Operational/Managerial Control · Individual

0% 1 facilities 2025-04-01
James, Michael

Operational/Managerial Control · Individual

0% 2 facilities 2025-04-01
Liberty Commons Nursing & Rehab Of Johnston County, LLC

5% Or Greater Direct Ownership Interest · Organization

0% 1 facilities 2002-10-01
Liberty Long Term Care LLC

5% Or Greater Direct Ownership Interest · Organization

0% 21 facilities 2025-04-01
Miller, Robert

Corporate Director · Individual

0% 34 facilities 2025-04-01
Wilson, Jeffrey

Corporate Officer · Individual

0% 36 facilities 2025-04-01

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Staffing
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Fines
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