Your report for Louisburg Healthcare & Rehabilitation Center
Overall Score
CMS Five-Star Quality Rating- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- North CarolinaLowest tier among peers417 rated homes · average 2.9★
- United StatesLowest tier among peers14,574 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point2★−0.9 vs NC avg
- StaffingCan add or remove a star1★−1.7 vs NC avg
- Quality measuresCan add or remove a star3★−0.2 vs NC avg
CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles2★Above only 17% of peersNC avg2.9★U.S. avg2.8★
Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.
It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.
Staffing ratingCMS stars from payroll-reported hours and turnover1★Lowest tier among peersNC avg2.7★U.S. avg2.9★
Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.
More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.
Quality measures ratingCMS stars from clinical outcomes and resident assessments3★Above only 30% of peersNC avg3.2★U.S. avg3.6★
Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.
It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.
Total nurse hoursPer resident per day, all nursing staff3.07hrsAbove only 6% of peersNC avg3.78Benchmark4.10
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.
RN hoursPer resident per day, registered nurses only0.37hrsAbove only 20% of peersNC avg0.59Benchmark0.75
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.
Nursing staff turnoverShare of nursing staff who left within a year · lower is better71%Above only 9% of peersNC avg50%RN turnover82%
The share of nursing staff who left within the past year, from the same payroll data.
High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.
Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$153,104Above only 9% of peersNC avg$45,050Fines · denials3 · 2
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cyclesCitations by monthDec 2022 – Mar 2025
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Mar 6, 2025Cycle 1worst E · no actual harm
- F687Provide appropriate foot care.Quality of Life and CareD · isolatedCorrected Mar 27, 2025
- F554Allow residents to self-administer drugs if determined clinically appropriate.Resident RightsD · isolatedCorrected Mar 27, 2025
- F565Honor the resident's right to organize and participate in resident/family groups in the facility.Resident RightsE · patternCorrected Mar 27, 2025
- F585Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Resident RightsB · patternCorrected Mar 27, 2025
- F727Have 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.Nursing and Physician ServicesD · isolatedCorrected Mar 27, 2025
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryD · isolatedCorrected Mar 27, 2025
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Mar 27, 2025
Aug 28, 2024Cycle 2worst D · no actual harm
- F760Ensure that residents are free from significant medication errors.Pharmacy ServiceD · isolatedCorrected Sep 17, 2024
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Sep 17, 2024
Jul 10, 2024Cycle 2worst K · immediate jeopardy$133,854, payment denial
- F925Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.EnvironmentalK · patternCorrected Aug 28, 2024
Mar 6, 2024Cycle 2worst E · no actual harm
- F883Develop and implement policies and procedures for flu and pneumonia vaccinations.Infection ControlD · isolatedCorrected Apr 11, 2024
- F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Resident Assessment and Care PlanningD · isolatedCorrected Mar 23, 2024
- F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care PlanningD · isolatedCorrected Mar 23, 2024
- F698Provide safe, appropriate dialysis care/services for a resident who requires such services.Quality of Life and CareD · isolatedCorrected Apr 11, 2024
- F756Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.Pharmacy ServiceE · patternCorrected Apr 11, 2024
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningD · isolatedCorrected Apr 11, 2024
- F867Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.AdministrationD · isolatedCorrected Mar 23, 2024
- F761Ensure 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.Pharmacy ServiceD · isolatedCorrected Apr 11, 2024
Oct 5, 2023Cycle 3worst D · no actual harm
- F761Ensure 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.Pharmacy ServiceD · isolatedCorrected Oct 28, 2023
- F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Resident Assessment and Care PlanningB · patternCorrected Oct 28, 2023
- F759Ensure medication error rates are not 5 percent or greater.Pharmacy ServiceD · isolatedCorrected Oct 28, 2023
- F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Oct 28, 2023
Sep 1, 2023Cycle 3worst J · immediate jeopardy$3,981, $15,269, payment denial
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareJ · isolatedCorrected Oct 5, 2023
Dec 14, 2022Cycle 3worst D · no actual harm
- F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected Dec 16, 2022
- F732Post nurse staffing information every day.Nursing and Physician ServicesC · widespreadCorrected Dec 16, 2022
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryD · isolatedCorrected Dec 16, 2022
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined3.07hrs
- Registered nursesRN hours only0.37hrs
- Licensed practical nursesLPN hours0.71hrs
- Nurse aidesCNA hours1.99hrs
- Weekend nursingAll staff on Saturdays and Sundays2.63hrs
- North Carolina average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better71%Above only 9% of peersNC avg 50%
- RN turnoverRegistered nurses only82%Not ranked by CMS
- Administrators who leftIn the past year1Leadership changed
- Occupancy92 certified beds · ~89 residents a day96%Top 7%NC avg 83%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $153,104In fines
- 3Fines
- 2Payment denials
- $45,050NC avg in fines
Actions on record
- Jul 10, 2024Civil money penalty$133,854
- Jul 10, 2024Denial of payment for new admissionsfrom Aug 8, 2024
- Sep 1, 2023Civil money penalty$3,981
- Sep 1, 2023Civil money penalty$15,269
- Sep 1, 2023Denial of payment for new admissionsfrom Sep 26, 2023
Ownership
As filed with CMSStructure
- Ownership type
- For profit - Limited Liability company
- Chain
- Liberty Senior Living34 facilities in the chain2.6★ chain average
- Certification
- Medicare and Medicaid
- Location type
- Urban
- Ownership change
- None in the last 12 months
People and entities on file
- Liberty Healthcare Group LLC
- John a McNeill Jr 2012 Irrv Tr
- Ronald B and Cynthia J McNeill 2013 Irrv Tr
- John McNeill
- Ronald McNeill
- Long Term Care Management Services LLC
- Joeseph V Calcutt
- Jeffrey Wilson
- Robert Miller
- Jeffrey Wilson
- Deidra Sykes
Person Organization
Sources & notes
Public data, updated quarterlyData sources
- CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
- CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
- CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.
Notes
- CMS Certification Number 345358 · 202 Smoketree Way, Louisburg, NC, 27549.
- Percentiles compare this facility with every rated nursing home in North Carolina and Franklin County. Turnover and fines are inverted so a high percentile is always good.
- This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.
