Cycle 1
Health 2025-11-20 · Fire 2024-08-29
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Falcon, NC
Liberty Healthcare Services of Golden Years Nursin
3-star overall rating with 4-star inspections with 2 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
7348 North West Street, Falcon, NC
(910) 980-1271
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
58
Certified beds
Average residents
51
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Liberty Senior Living
Operator or chain grouping
Approved since
1991-05-03
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
0.41
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.92
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
1.95
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.29
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.34
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
2.90
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.32
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.37
CMS adjusted RN staffing hours
Adjusted total hours
2.94
CMS adjusted total nurse staffing hours
Case-mix index
1.53
Higher values indicate more complex resident acuity
RN turnover
100%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
67%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,961
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.92
Composite VBP score used to determine payment impact.
Payment multiplier
0.9827
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
4.22
Baseline 33.33% · Performance 46.43% · Measure score 4.22 · Achievement 4.22 · Improvement 0
Adjusted total nurse staffing
0.16
Baseline 2.27 hours · Performance 2.50 hours · Measure score 0.16 · Achievement 0 · Improvement 0.16
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays 16 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 16 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | Not Available |
1.02
|
Too few residents or stays to report publicly. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator 9 · Adjusted rate Not Available · Too few residents or stays to report publicly. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 8 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 24.44% |
8.2%
16.2 pts better
|
Numerator 11 · Denominator 45 |
| Staff flu vaccination coverage | 16.95% |
42%
25.1 pts worse
|
Numerator 10 · Denominator 59 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.4% |
91.5%
0.1 pts worse
|
93.4%
2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 86.7% · Q2 84.8% · Q3 97.8% · Q4 95.9% · 4Q avg 91.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.2% |
94.1%
1.9 pts worse
|
95.5%
3.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.6%
3.6 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · 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 | 6.1% |
7.2%
1.1 pts better
|
5.4%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 4.9% · Q3 10.0% · Q4 2.4% · 4Q avg 6.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 8.6% |
21.6%
13 pts better
|
19.6%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.5% · Q2 7.3% · Q3 7.5% · Q4 11.9% · 4Q avg 8.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 15.4% |
15.0%
0.4 pts worse
|
16.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 13.2% · Q3 15.4% · Q4 16.7% · 4Q avg 15.4% · 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 need for help with daily activities has increased | 12.3% |
16.8%
4.5 pts better
|
14.9%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 6.5% · Q3 12.9% · Q4 17.1% · 4Q avg 12.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.6% |
0.9%
0.3 pts better
|
1.0%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 0.0% · Q4 1.0% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.8% |
2.6%
1.2 pts worse
|
1.7%
2.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 4.4% · Q4 8.2% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 9.7% |
21.2%
11.5 pts better
|
19.8%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.6% · Q2 3.2% · Q3 11.4% · Q4 14.2% · 4Q avg 9.7% |
| Percentage of long-stay residents with pressure ulcers | 5.6% |
6.0%
0.4 pts better
|
5.1%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 4.2% · Q3 5.1% · Q4 10.0% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 68.6% |
79.9%
11.3 pts worse
|
81.7%
13.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 66.7% · Q2 62.5% · Q3 72.2% · Q4 72.2% · 4Q avg 68.6% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 72.7% |
78.1%
5.4 pts worse
|
79.7%
7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 72.7% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-29 · Fire 2023-08-03
1 health deficiencies
Top issue: Resident Assessment and Care Planning (1 deficiency)
1 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2023-08-03 · Fire 2022-03-18
4 health deficiencies
Top issue: Administration (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-08-29
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-08-29
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-11-15
E · Potential for more than minimal harm
2024-08-29
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-08-29
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-08-29
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-11-15
D · Potential for more than minimal harm
2024-08-29
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-11-15
F · Potential for more than minimal harm
2023-08-03
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-10-02
Inspection history
Recent health citations
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 2025-12-09
D · Potential for more than minimal harm
2025-03-10
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-03-15
D · Potential for more than minimal harm
2024-08-29
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-09-20
D · Potential for more than minimal harm
2023-08-03
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-08-24
D · Potential for more than minimal harm
2023-08-03
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-08-24
C · Minimal harm
2023-08-03
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2023-08-24
B · Minimal harm
2023-08-03
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-08-24
Penalties and ownership
What sits behind the stars
Ownership
Calcutt, Joeseph V
Corporate Officer · Individual
Cooper, Marcus
Operational/Managerial Control · Individual
Liberty Healthcare Services Of Golden Years Nursing Center, LLC
5% Or Greater Direct Ownership Interest · Organization
Liberty Long Term Care LLC
Operational/Managerial Control · Organization
Mcneill, Robert
Corporate Director · Individual
Miller, Robert
Corporate Director · Individual
Rao, Lakshman
Operational/Managerial Control · Individual
Wilson, Jeffrey
Corporate Officer · Individual
Nearby options
Other facilities in reach
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The Carrolton of Dunn
Dunn, NC
1-star overall rating with 1-star inspections with $61,389 in total fines with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#2
Harnett Woods Nursing and Rehabilitation Center
Dunn, NC
4-star overall rating with 4-star inspections with 2 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Bethesda Health Care Facility
Eastover, NC
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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