Wilmington, NC
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
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
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
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
RN hours / resident day
0.51
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.90
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
1.85
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
1.42
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
2.95
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.34
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.08
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.56
CMS adjusted RN staffing hours
Adjusted total hours
3.57
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
64%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Program rank
10,758
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.2
Composite VBP score used to determine payment impact.
Payment multiplier
0.9821
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
Readmission
2.86
Baseline 17.18% · Performance 20.10% · Measure score 2.86 · Achievement 2.86 · Improvement 0
Healthcare-associated infections
1.83
Baseline 5.33% · Performance 7.29% · Measure score 1.83 · Achievement 1.83 · Improvement 0
Total nurse turnover
1.64
Baseline 62.69% · Performance 56.96% · Measure score 1.64 · Achievement 1.64 · Improvement 1.01
Adjusted total nurse staffing
1.34
Baseline 3.09 hours · Performance 3.46 hours · Measure score 1.34 · Achievement 1.34 · Improvement 0.88
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.47% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 176 · Observed rate 10.23% · Lower 95% interval 7.11% |
| Discharge to community | 58.03% |
50.57%
7.5 pts better
|
Better than the National Rate · Eligible stays 178 · Observed rate 51.12% · Lower 95% interval 50.88% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 87.5% |
95.27%
7.8 pts worse
|
Numerator 98 · Denominator 112 |
| Falls with major injury | 1.79% |
0.77%
1 pts worse
|
Numerator 2 · Denominator 112 |
| Discharge self-care score | 56.1% |
53.69%
2.4 pts better
|
Numerator 46 · Denominator 82 |
| Discharge mobility score | 48.78% |
50.94%
2.2 pts worse
|
Numerator 40 · Denominator 82 |
| Pressure ulcers or injuries, new or worsened | 3.57% |
2.29%
1.3 pts worse
|
Numerator 4 · Denominator 112 · Adjusted rate 3.93% |
| Healthcare-associated infections requiring hospitalization | 7.29% |
7.12%
0.2 pts worse
|
No Different than the National Rate · Eligible stays 114 · Observed rate 7.02% · Lower 95% interval 4.34% |
| Staff COVID-19 vaccination coverage | 8% |
8.2%
0.2 pts worse
|
Numerator 8 · Denominator 100 |
| Staff flu vaccination coverage | 48% |
42%
6 pts better
|
Numerator 48 · Denominator 100 |
| Discharge function score | 56.1% |
56.45%
0.4 pts worse
|
Numerator 46 · Denominator 82 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 26 · Denominator 26 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 72 · Denominator 72 |
| Resident COVID-19 vaccinations up to date | 13.21% |
25.2%
12 pts worse
|
Numerator 7 · Denominator 53 |
Quality measures
| 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 · Adjusted 2.2 · Observed 1.5 · Expected 1.3 · Used in QM five-star |
| 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 · Adjusted 1.8 · Observed 1.3 · Expected 1.3 · Used in QM five-star |
| 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 · Q1 91.8% · Q2 98.4% · Q3 94.9% · Q4 90.6% · 4Q avg 93.9% |
| 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 · 4Q avg 88.9% |
| 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 4.9% · Q2 4.8% · Q3 1.7% · Q4 1.6% · 4Q avg 3.3% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 1.8% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% |
| 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 · Q1 7.8% · Q2 2.0% · Q3 8.3% · Q4 0.0% · 4Q avg 4.5% |
| 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 · Q1 21.6% · Q2 15.7% · Q3 18.8% · Q4 17.3% · 4Q avg 18.3% |
| 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 · Q1 15.0% · Q2 10.3% · Q3 12.5% · Q4 8.9% · 4Q avg 11.6% · 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 | 5.6% |
21.5%
15.9 pts better
|
16.3%
10.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.6% · Used in QM five-star |
| 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 · Q1 2.1% · Q2 10.2% · Q3 2.2% · Q4 6.1% · 4Q avg 5.3% · Used in QM five-star |
| 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 · Q1 3.3% · Q2 1.5% · Q3 1.4% · Q4 1.1% · 4Q avg 1.8% · Used in QM five-star |
| 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 · Q1 0.0% · Q2 0.0% · Q3 1.7% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| 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 · Q1 29.8% · Q2 17.5% · Q3 18.8% · Q4 28.9% · 4Q avg 23.8% |
| 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 · Q1 1.6% · Q2 3.2% · Q3 5.0% · Q4 4.4% · 4Q avg 3.6% · Used in QM five-star |
| 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 · Q1 93.7% · Q2 89.5% · Q3 90.1% · Q4 88.5% · 4Q avg 90.5% |
| 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 · Adjusted 11.7% · Observed 10.1% · Expected 9.7% · Used in QM five-star |
| 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 · Q1 1.2% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| 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 · 4Q avg 84.1% |
| 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 · Adjusted 24.8% · Observed 20.2% · Expected 19.4% · Used in QM five-star |
Survey summary
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)
Top issue: Nutrition and Dietary (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Top issue: Infection Control (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
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
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
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2025-03-21
Fire Safety
Ensure electrical receptacles or cover plates have distinctive color or marking.
Corrected 2025-03-21
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-03-21
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2023-12-15
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-12-15
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
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-09-12
Fire Safety
Install noncombustible or limited-combustible interior walls.
Corrected 2022-09-12
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-09-12
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2022-09-12
Inspection history
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
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-01-31
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-01-31
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
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-11-08
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2023-12-15
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-12-15
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
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
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-12-15
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2023-12-15
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-12-15
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
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
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
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2022-08-12
Health
Ensure staff are vaccinated for COVID-19
Corrected 2022-08-10
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2022-08-11
Health
Perform COVID19 testing on residents and staff.
Corrected 2022-08-05
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
Health
Ensure each resident receives an accurate assessment.
Corrected 2022-08-12
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
Fine · fine $9,620
Fine
Fine · fine $11,368
Fine
Payment Denial · denial start 2023-12-01 · 14 days
14 day denial
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
W-2 Managing Employee · Individual
W-2 Managing Employee · Individual
Operational/Managerial Control · Individual
Operational/Managerial Control · Organization
5% Or Greater Direct Ownership Interest · Individual
Corporate Director · Individual
5% Or Greater Direct Ownership Interest · Individual
Corporate Director · Individual
Corporate Director · Individual
W-2 Managing Employee · Individual
Nearby options
Wilmington, NC
5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
Wilmington, NC
3-star overall rating with 3-star inspections with $5,244 in total fines with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
Wilmington, NC
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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