Cycle 1
Health 2025-07-10 · Fire 2024-07-26
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Whiteville, NC
Liberty Commons Nursing and Rehabilitation Center
1-star overall rating with 1-star inspections with $135,234 in total fines with 5 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
1402 Pinckney Street, Whiteville, NC
(910) 642-4245
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
107
Certified beds
Average residents
99
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Liberty Senior Living
Operator or chain grouping
Approved since
1981-10-01
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
0.38
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.99
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.72
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
4.09
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.37
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.60
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.18
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.05
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.41
CMS adjusted RN staffing hours
Adjusted total hours
4.45
CMS adjusted total nurse staffing hours
Case-mix index
1.26
Higher values indicate more complex resident acuity
RN turnover
46%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,980
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.19
Composite VBP score used to determine payment impact.
Payment multiplier
0.9849
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
3.43
Baseline 20.62% · Performance 19.84% · Measure score 3.43 · Achievement 3.43 · Improvement 1.68
Healthcare-associated infections
2.34
Baseline 9.83% · Performance 8.46% · Measure score 2.34 · Achievement 0 · Improvement 2.34
Total nurse turnover
2.80
Baseline 50.00% · Performance 52.22% · Measure score 2.80 · Achievement 2.80 · Improvement 0
Adjusted total nurse staffing
2.69
Baseline 3.22 hours · Performance 3.84 hours · Measure score 2.69 · Achievement 2.69 · Improvement 1.95
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 8.91% |
10.72%
1.8 pts better
|
No Different than the National Rate · Eligible stays 154 · Observed rate 6.49% · Lower 95% interval 6.2% |
| Discharge to community | 65% |
50.57%
14.4 pts better
|
Better than the National Rate · Eligible stays 149 · Observed rate 62.42% · Lower 95% interval 57.19% |
| Medicare spending per beneficiary | 1.13 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 95.51% |
95.27%
0.2 pts better
|
Numerator 85 · Denominator 89 |
| Falls with major injury | 2.25% |
0.77%
1.5 pts worse
|
Numerator 2 · Denominator 89 |
| Discharge self-care score | 61.54% |
53.69%
7.9 pts better
|
Numerator 40 · Denominator 65 |
| Discharge mobility score | 44.62% |
50.94%
6.3 pts worse
|
Numerator 29 · Denominator 65 |
| Pressure ulcers or injuries, new or worsened | 6.74% |
2.29%
4.5 pts worse
|
Numerator 6 · Denominator 89 · Adjusted rate 5.63% |
| Healthcare-associated infections requiring hospitalization | 8.46% |
7.12%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 101 · Observed rate 9.9% · Lower 95% interval 5.16% |
| Staff COVID-19 vaccination coverage | 8.66% |
8.2%
0.5 pts better
|
Numerator 11 · Denominator 127 |
| Staff flu vaccination coverage | 23.85% |
42%
18.1 pts worse
|
Numerator 31 · Denominator 130 |
| Discharge function score | 38.46% |
56.45%
18 pts worse
|
Numerator 25 · Denominator 65 |
| Transfer of health information to provider | 59.72% |
95.95%
36.2 pts worse
|
Numerator 43 · Denominator 72 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 6.25% |
25.2%
18.9 pts worse
|
Numerator 3 · Denominator 48 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.8
About the same
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 2.2 · Expected 2.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.7 |
1.8
0.1 pts better
|
1.8
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.6 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 91.7% |
91.5%
0.2 pts better
|
93.4%
1.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 98.6% · Q2 92.0% · Q3 88.0% · Q4 89.0% · 4Q avg 91.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 80.2% |
94.1%
13.9 pts worse
|
95.5%
15.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 80.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.8% |
3.6%
0.8 pts better
|
3.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 2.3% · Q3 3.6% · Q4 3.7% · 4Q avg 2.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.0% |
4.8%
3.8 pts better
|
11.4%
10.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.2% · Q3 2.5% · Q4 0.0% · 4Q avg 1.0% |
| Percentage of long-stay residents who lose too much weight | 3.7% |
7.2%
3.5 pts better
|
5.4%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 9.2% · Q3 1.6% · Q4 0.0% · 4Q avg 3.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 14.6% |
21.6%
7 pts better
|
19.6%
5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 15.4% · Q3 16.1% · Q4 16.9% · 4Q avg 14.6% |
| Percentage of long-stay residents who received an antipsychotic medication | 26.0% |
15.0%
11 pts worse
|
16.7%
9.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.8% · Q2 25.8% · Q3 28.8% · Q4 27.9% · 4Q avg 26.0% · 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 | 31.2% |
21.5%
9.7 pts worse
|
16.3%
14.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q2 40.8% · Q4 28.6% · 4Q avg 31.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.3% |
16.8%
1.5 pts better
|
14.9%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 8.3% · Q3 25.0% · Q4 18.6% · 4Q avg 15.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.8% |
0.9%
0.1 pts better
|
1.0%
0.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 0.9% · Q4 1.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 5.6% |
2.6%
3 pts worse
|
1.7%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.7% · Q2 4.6% · Q3 4.8% · Q4 3.7% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.9% |
21.2%
3.7 pts worse
|
19.8%
5.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 26.1% · Q2 34.1% · Q3 17.8% · Q4 21.1% · 4Q avg 24.9% |
| Percentage of long-stay residents with pressure ulcers | 4.6% |
6.0%
1.4 pts better
|
5.1%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.8% · Q3 3.8% · Q4 5.7% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.4% |
79.9%
12.5 pts better
|
81.7%
10.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.5% · Q2 89.4% · Q3 92.4% · Q4 98.2% · 4Q avg 92.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.2% |
13.2%
About the same
|
12.0%
1.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.2% · Observed 13.0% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.5% |
1.5%
2 pts worse
|
1.6%
1.9 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 3.9% · Q3 2.3% · Q4 3.9% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 85.9% |
78.1%
7.8 pts better
|
79.7%
6.2 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 85.9% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 18.0% |
22.9%
4.9 pts better
|
23.9%
5.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 18.0% · Observed 18.2% · Expected 24.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-07-26 · Fire 2023-05-04
6 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2023-05-04 · Fire 2022-04-05
16 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-07-26
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 2024-09-12
D · Potential for more than minimal harm
2023-05-04
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 2023-08-25
D · Potential for more than minimal harm
2023-05-04
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-08-25
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-07-10
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 2025-07-31
E · Potential for more than minimal harm
2025-07-10
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-07-31
D · Potential for more than minimal harm
2025-07-10
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-07-31
D · Potential for more than minimal harm
2025-07-10
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-07-31
D · Potential for more than minimal harm
2025-07-10
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2025-07-31
K · Immediate jeopardy
2024-07-26
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-07-27
K · Immediate jeopardy
2024-07-26
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-07-27
F · Potential for more than minimal harm
2024-07-26
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 2024-08-18
E · Potential for more than minimal harm
2024-07-26
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2024-08-18
E · Potential for more than minimal harm
2024-07-26
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-08-18
E · Potential for more than minimal harm
2024-07-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-18
G · Actual harm
2024-02-29
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-01-08
G · Actual harm
2024-02-29
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 2024-01-09
G · Actual harm
2024-02-29
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-03-20
E · Potential for more than minimal harm
2024-02-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-03-04
D · Potential for more than minimal harm
2024-02-29
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2024-02-19
G · Actual harm
2023-09-15
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 2023-09-12
G · Actual harm
2023-09-15
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-09-27
G · Actual harm
2023-05-04
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 2023-05-24
E · Potential for more than minimal harm
2023-05-04
F636 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Corrected 2023-05-24
E · Potential for more than minimal harm
2023-05-04
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 2023-05-24
E · Potential for more than minimal harm
2023-05-04
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 2023-05-24
E · Potential for more than minimal harm
2023-05-04
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-05-24
D · Potential for more than minimal harm
2023-05-04
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2023-05-24
D · Potential for more than minimal harm
2023-05-04
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-05-24
D · Potential for more than minimal harm
2023-05-04
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-05-24
C · Minimal harm
2023-05-04
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-05-24
Penalties and ownership
What sits behind the stars
$69,518
2024-07-26
Fine
Fine · fine $69,518
Fine
$45,429
2024-02-29
Fine
Fine · fine $45,429
Fine
$4,196
2023-09-15
Fine
Fine · fine $4,196
Fine
$7,443
2023-09-15
Fine
Fine · fine $7,443
Fine
$8,648
2023-05-04
Fine
Fine · fine $8,648
Fine
Ownership
Bork, Matthew
Operational/Managerial Control · Individual
Calcutt, Joeseph V
Operational/Managerial Control · Individual
Calcutt, Joeseph V
W-2 Managing Employee · Individual
Hamric, Anthony
Operational/Managerial Control · Individual
Jones, Tracey
W-2 Managing Employee · Individual
Liberty Healthcare Management Inc
Operational/Managerial Control · Organization
Long Term Care Management Services LLC
5% Or Greater Direct Ownership Interest · Organization
Mcneill, John
5% Or Greater Direct Ownership Interest · Individual
Mcneill, John
Corporate Director · Individual
Mcneill, Ronald
5% Or Greater Direct Ownership Interest · Individual
Mcneill, Ronald
Corporate Director · Individual
Purifoy, Penny
Corporate Director · Individual
Wilson, Jeffrey
W-2 Managing Employee · Individual
Nearby options
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#3
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2-star overall rating with 4-star inspections with $15,811 in total fines with 3 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
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