01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-03-06 | 7 | 2025-03-06 | 3 |
| Cycle 2 | 2024-03-06 | 10 | 2024-03-06 | 4 |
| Cycle 3 | 2022-12-14 | 9 | 2022-12-14 | 3 |
CMS CCN 3453582026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Louisburg Healthcare & Rehabilitation Center
202 Smoketree Way · Louisburg, NC 27549 · Franklin County
Certified beds92CMS provider file
Recent citation rows36current CMS citation release
Penalty rows5current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
36 rows in the current release
2 rows carry G–L scope/severity codes; 2 carry J–L. 3 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-03-06 · HEALTHF0550Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Correction field: Deficient, Provider has date of correction · 2025-03-27 · complaint2025-03-06 · HEALTHF0554Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
Correction field: Deficient, Provider has date of correction · 2025-03-272025-03-06 · HEALTHF0565Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to organize and participate in resident/family groups in the facility.
Correction field: Deficient, Provider has date of correction · 2025-03-272025-03-06 · HEALTHF0585Severity B · pattern; potential for minimal harm
Resident Rights Deficiencies
Honor 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.
Correction field: Deficient, Provider has plan of correction · 2025-03-272025-03-06 · HEALTHF0687Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate foot care.
Correction field: Deficient, Provider has date of correction · 2025-03-27 · complaint2025-03-06 · HEALTHF0727Severity D · isolated; potential for more than minimal harm
Nursing and Physician Services Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-03-272025-03-06 · HEALTHF0812Severity D · isolated; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2025-03-272025-03-06 · FIREK0352Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2025-04-152025-03-06 · FIREK0353Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2025-04-152025-03-06 · FIREK0916Severity D · isolated; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Correction field: Deficient, Provider has date of correction · 2025-04-152024-08-28 · HEALTHF0755Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2024-09-17 · complaint2024-08-28 · HEALTHF0760Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
Correction field: Deficient, Provider has date of correction · 2024-09-17 · complaint2024-07-10 · HEALTHF0925Severity K · pattern of immediate jeopardy
Environmental Deficiencies
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Correction field: Deficient, Provider has date of correction · 2024-08-28 · complaint2024-03-06 · HEALTHF0644Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Correction field: Deficient, Provider has date of correction · 2024-03-232024-03-06 · HEALTHF0655Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Correction field: Deficient, Provider has date of correction · 2024-03-232024-03-06 · HEALTHF0698Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Correction field: Deficient, Provider has date of correction · 2024-04-112024-03-06 · HEALTHF0756Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Correction field: Deficient, Provider has date of correction · 2024-04-112024-03-06 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-04-11 · complaint2024-03-06 · HEALTHF0842Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Correction field: Deficient, Provider has date of correction · 2024-04-112024-03-06 · HEALTHF0867Severity D · isolated; potential for more than minimal harm
Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Correction field: Deficient, Provider has date of correction · 2024-03-232024-03-06 · HEALTHF0883Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Correction field: Deficient, Provider has date of correction · 2024-04-112024-03-06 · FIREK0321Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2024-06-042024-03-06 · FIREK0324Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Provide properly protected cooking facilities.
Correction field: Deficient, Provider has date of correction · 2024-06-042024-03-06 · FIREK0500Severity F · widespread; potential for more than minimal harm
Services Deficiencies
Meet other general requirements that are deficient.
Correction field: Deficient, Provider has date of correction · 2024-06-0403 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2024-07-10 | Fine | $133,854 | 0 |
| 2024-07-10 | Payment Denial | $0 | 40 |
| 2023-09-01 | Fine | $3,981 | 0 |
| 2023-09-01 | Fine | $15,269 | 0 |
| 2023-09-01 | Payment Denial | $0 | 32 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- LIBERTY HEALTHCARE GROUP LLCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 02/01/2020
- SYKES, DEIDRAIndividual · W-2 MANAGING EMPLOYEENOT APPLICABLE · since 09/05/2023
- WILSON, JEFFREYIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 02/01/2020
- LONG TERM CARE MANAGEMENT SERVICES LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 02/01/2020
- CALCUTT, JOSEPHIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 02/01/2020
- WILSON, JEFFREYIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 02/01/2020
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.16per resident day
RN hours0.35per resident day
Weekend nurse hours2.64per resident day
Staff turnover51.3%CMS reported field
06 / LOCAL RECORDS
Open the Louisburg ledger →