Wilmington, NC

Liberty Commons Rehabilitation Center

2-star overall rating with 2-star inspections with abuse icon flag with $20,988 in total fines with 4 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle

121 Racine Drive, Wilmington, NC

(910) 452-4070

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

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

82

Certified beds

Average residents

79

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Liberty Senior Living

Operator or chain grouping

Approved since

1994-11-18

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Staffing

Hours and turnover

RN hours / resident day

0.51

Registered nurse staffing

LPN hours / resident day

0.90

Licensed practical nurse staffing

Aide hours / resident day

1.85

Nurse aide staffing

Weekend hours

2.95

Weekend nurse staffing

RN turnover

50%

Annual RN turnover

Total nurse turnover

64%

Annual nurse turnover

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 2.2
1.8
0.4 pts worse
1.9
0.3 pts worse
Long Stay · 20240701-20250630
Number of outpatient emergency department visits per 1000 long-stay resident days 1.8
1.8
About the same
1.8
About the same
Long Stay · 20240701-20250630
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 93.9%
91.5%
2.4 pts better
93.4%
0.5 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 88.9%
94.1%
5.2 pts worse
95.5%
6.6 pts worse
Long Stay · 2024Q3-2025Q2
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
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 4.5%
7.2%
2.7 pts better
5.4%
0.9 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antianxiety or hypnotic medication 18.3%
21.6%
3.3 pts better
19.6%
1.3 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents who received an antipsychotic medication 11.6%
15.0%
3.4 pts better
16.7%
5.1 pts better
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 5.6%
21.5%
15.9 pts better
16.3%
10.7 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents whose need for help with daily activities has increased 5.3%
16.8%
11.5 pts better
14.9%
9.6 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a catheter inserted and left in their bladder 1.8%
0.9%
0.9 pts worse
1.0%
0.8 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with a urinary tract infection 0.4%
2.6%
2.2 pts better
1.7%
1.3 pts better
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 23.8%
21.2%
2.6 pts worse
19.8%
4 pts worse
Long Stay · 2024Q4-2025Q3
Percentage of long-stay residents with pressure ulcers 3.6%
6.0%
2.4 pts better
5.1%
1.5 pts better
Long Stay · 2024Q4-2025Q3
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 90.5%
79.9%
10.6 pts better
81.7%
8.8 pts better
Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who had an outpatient emergency department visit 11.7%
13.2%
1.5 pts better
12.0%
0.3 pts better
Short Stay · 20240701-20250630
Percentage of short-stay residents who newly received an antipsychotic medication 0.3%
1.5%
1.2 pts better
1.6%
1.3 pts better
Short Stay · 2024Q4-2025Q3
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 84.1%
78.1%
6 pts better
79.7%
4.4 pts better
Short Stay · 2024Q3-2025Q2
Percentage of short-stay residents who were rehospitalized after a nursing home admission 24.8%
22.9%
1.9 pts worse
23.9%
0.9 pts worse
Short Stay · 20240701-20250630

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-01-22 · Fire 2025-01-22

4 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)

5 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)

Cycle 2 Health 2023-11-02 · Fire 2023-11-02

10 health deficiencies

Top issue: Nutrition and Dietary (3 deficiencies)

3 fire-safety deficiencies

Top issue: Smoke (3 deficiencies)

Cycle 3 Health 2022-07-15 · Fire 2022-07-15

8 health deficiencies

Top issue: Infection Control (3 deficiencies)

4 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Fire safety

Fire-safety citations

E · Potential for more than minimal harm 2025-01-22

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 2025-03-21

D · Potential for more than minimal harm 2025-01-22

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 2025-03-21

D · Potential for more than minimal harm 2025-01-22

K342 · Smoke Deficiencies

Fire Safety

Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.

Corrected 2025-03-21

D · Potential for more than minimal harm 2025-01-22

K917 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure electrical receptacles or cover plates have distinctive color or marking.

Corrected 2025-03-21

D · Potential for more than minimal harm 2025-01-22

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2025-03-21

F · Potential for more than minimal harm 2023-11-02

K342 · Smoke Deficiencies

Fire Safety

Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.

Corrected 2023-12-15

F · Potential for more than minimal harm 2023-11-02

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-12-15

D · Potential for more than minimal harm 2023-11-02

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 2023-12-15

F · Potential for more than minimal harm 2022-07-15

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2022-09-12

D · Potential for more than minimal harm 2022-07-15

K163 · Construction Deficiencies

Fire Safety

Install noncombustible or limited-combustible interior walls.

Corrected 2022-09-12

D · Potential for more than minimal harm 2022-07-15

K341 · Smoke Deficiencies

Fire Safety

Install a fire alarm system that can be heard throughout the facility.

Corrected 2022-09-12

D · Potential for more than minimal harm 2022-07-15

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2022-09-12

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-03-12

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 2025-03-06

G · Actual harm 2025-01-22

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2025-01-31

D · Potential for more than minimal harm 2025-01-22

F684 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-01-31

B · Minimal harm 2025-01-22

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 2025-01-31

G · Actual harm 2023-11-02

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 2022-11-08

E · Potential for more than minimal harm 2023-11-02

F565 · Resident Rights Deficiencies

Health

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

Corrected 2023-12-15

E · Potential for more than minimal harm 2023-11-02

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2023-12-15

E · Potential for more than minimal harm 2023-11-02

F809 · Nutrition and Dietary Deficiencies

Health

Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

Corrected 2023-12-15

E · Potential for more than minimal harm 2023-11-02

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 2023-12-15

E · Potential for more than minimal harm 2023-11-02

F867 · Administration Deficiencies

Health

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

Corrected 2023-12-15

D · Potential for more than minimal harm 2023-11-02

F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from the wrongful use of the resident's belongings or money.

Corrected 2023-12-15

D · Potential for more than minimal harm 2023-11-02

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2023-12-15

D · Potential for more than minimal harm 2023-11-02

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 2023-12-15

D · Potential for more than minimal harm 2023-11-02

F849 · Administration Deficiencies

Health

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Corrected 2023-12-15

J · Immediate jeopardy 2022-07-15

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 2022-06-13

G · Actual harm 2022-07-15

F835 · Administration Deficiencies

Health

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Corrected 2022-08-12

G · Actual harm 2022-07-15

F888 · Infection Control Deficiencies

Health

Ensure staff are vaccinated for COVID-19

Corrected 2022-08-10

E · Potential for more than minimal harm 2022-07-15

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2022-08-11

E · Potential for more than minimal harm 2022-07-15

F886 · Infection Control Deficiencies

Health

Perform COVID19 testing on residents and staff.

Corrected 2022-08-05

D · Potential for more than minimal harm 2022-07-15

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 2022-08-04

B · Minimal harm 2022-07-15

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2022-08-12

B · Minimal harm 2022-07-15

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 2022-08-05

Penalties and ownership

What sits behind the stars

$9,620 2025-01-22

Fine

Fine · fine $9,620

Fine

$11,368 2023-11-02

Fine

Fine · fine $11,368

Fine

$0 2023-11-02

Payment Denial

Payment Denial · denial start 2023-12-01 · 14 days

14 day denial

Ownership

Bork, Matthew

Operational/Managerial Control · Individual

0% 10 facilities 2007-01-29
Calcutt, Joeseph V

Operational/Managerial Control · Individual

0% 34 facilities 2003-11-03
Calcutt, Joeseph V

W-2 Managing Employee · Individual

0% 34 facilities 2010-01-01
Duff, Charles

W-2 Managing Employee · Individual

0% 1 facilities 2019-03-04
Hamric, Anthony

Operational/Managerial Control · Individual

0% 5 facilities 2005-01-24
Liberty Healthcare Management Inc

Operational/Managerial Control · Organization

0% 9 facilities 1994-11-18
Mcneill, John

5% Or Greater Direct Ownership Interest · Individual

0% 32 facilities 1994-11-18
Mcneill, John

Corporate Director · Individual

0% 32 facilities 2006-03-16
Mcneill, Ronald

5% Or Greater Direct Ownership Interest · Individual

0% 32 facilities 1994-11-18
Mcneill, Ronald

Corporate Director · Individual

0% 32 facilities 2006-03-16
Purifoy, Penny

Corporate Director · Individual

0% 13 facilities 2008-01-01
Wilson, Jeffrey

W-2 Managing Employee · Individual

0% 36 facilities 1994-11-18

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Staffing
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Overall
3 / 5
Health
3 / 5
Staffing
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Fines
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#3

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Overall
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Health
5 / 5
Staffing
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Fines
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