Cycle 1
Health 2025-05-01 · Fire 2025-05-01
6 health deficiencies
Top issue: Administration (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Southport, NC
Liberty Commons Nursing & Rehab Center of Southpor
3-star overall rating with 3-star inspections with 6 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
630 Fodale Avenue, Southport, NC
(910) 457-9581
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
99
Certified beds
Average residents
68
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Liberty Senior Living
Operator or chain grouping
Approved since
1991-05-31
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
0.68
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
1.04
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.00
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.72
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.72
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.50
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.52
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
0.73
CMS adjusted RN staffing hours
Adjusted total hours
3.96
CMS adjusted total nurse staffing hours
Case-mix index
1.29
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF VBP
Value-based purchasing
Program rank
8,112
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
27.78
Composite VBP score used to determine payment impact.
Payment multiplier
0.9847
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.32
Baseline 19.76% · Performance 20.82% · Measure score 1.32 · Achievement 1.32 · Improvement 0
Healthcare-associated infections
6.21
Baseline 7.77% · Performance 5.98% · Measure score 6.21 · Achievement 6.21 · Improvement 5.96
Total nurse turnover
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Adjusted total nurse staffing
0.80
Baseline 3.51 hours · Performance 3.31 hours · Measure score 0.80 · Achievement 0.80 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.31% |
10.72%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 189 · Observed rate 10.58% · Lower 95% interval 7.74% |
| Discharge to community | 57.08% |
50.57%
6.5 pts better
|
No Different than the National Rate · Eligible stays 186 · Observed rate 54.3% · Lower 95% interval 50.54% |
| Medicare spending per beneficiary | 0.91 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 50 · Denominator 50 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 50 |
| Discharge self-care score | 40.54% |
53.69%
13.1 pts worse
|
Numerator 15 · Denominator 37 |
| Discharge mobility score | 54.05% |
50.94%
3.1 pts better
|
Numerator 20 · Denominator 37 |
| Pressure ulcers or injuries, new or worsened | 2% |
2.29%
0.3 pts better
|
Numerator 1 · Denominator 50 · Adjusted rate 1.99% |
| Healthcare-associated infections requiring hospitalization | 5.98% |
7.12%
1.1 pts better
|
No Different than the National Rate · Eligible stays 100 · Observed rate 3% · Lower 95% interval 3.38% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 30 |
| Staff flu vaccination coverage | 16.3% |
42%
25.7 pts worse
|
Numerator 15 · Denominator 92 |
| Discharge function score | 56.76% |
56.45%
0.3 pts better
|
Numerator 21 · Denominator 37 |
| Transfer of health information to provider | 66.67% |
95.95%
29.3 pts worse
|
Numerator 16 · Denominator 24 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.4 |
1.8
1.4 pts better
|
1.9
1.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.5 · Expected 2.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.6 |
1.8
1.8 pts worse
|
1.8
1.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.6 · Observed 3.8 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 97.1% |
91.5%
5.6 pts better
|
93.4%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 98.0% · Q3 97.5% · Q4 95.7% · 4Q avg 97.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.1% |
3.6%
1.5 pts worse
|
3.3%
1.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.1% · Q3 2.5% · Q4 6.4% · 4Q avg 5.1% · 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 · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 2.6% |
7.2%
4.6 pts better
|
5.4%
2.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.9% · Q3 0.0% · Q4 2.4% · 4Q avg 2.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 32.8% |
21.6%
11.2 pts worse
|
19.6%
13.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.3% · Q3 30.3% · Q4 38.1% · 4Q avg 32.8% |
| 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 11.4% · Q3 11.5% · Q4 11.8% · 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% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 23.6% |
21.5%
2.1 pts worse
|
16.3%
7.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 23.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.4% |
16.8%
7.4 pts better
|
14.9%
5.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q3 10.3% · Q4 16.2% · 4Q avg 9.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 2.9% |
2.6%
0.3 pts worse
|
1.7%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q3 2.5% · Q4 4.3% · 4Q avg 2.9% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.0% |
21.2%
0.2 pts better
|
19.8%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.0% · Q3 30.2% · Q4 26.0% · 4Q avg 21.0% |
| Percentage of long-stay residents with pressure ulcers | 3.8% |
6.0%
2.2 pts better
|
5.1%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q3 6.3% · Q4 3.8% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 88.7% |
79.9%
8.8 pts better
|
81.7%
7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 86.2% · Q2 92.5% · Q3 89.4% · Q4 87.2% · 4Q avg 88.7% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 21.3% |
13.2%
8.1 pts worse
|
12.0%
9.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 21.3% · Observed 18.8% · Expected 9.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.1% |
1.5%
2.6 pts worse
|
1.6%
2.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 11.5% · Q3 5.3% · Q4 3.4% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 90.2% |
78.1%
12.1 pts better
|
79.7%
10.5 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 90.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.7% |
22.9%
0.8 pts worse
|
23.9%
0.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.7% · Observed 18.8% · Expected 18.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-07 · Fire 2024-03-07
7 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-11-21 · Fire 2022-11-21
18 health deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
2 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-05-01
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-07-12
D · Potential for more than minimal harm
2025-05-01
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2025-07-12
D · Potential for more than minimal harm
2025-05-01
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2025-07-12
F · Potential for more than minimal harm
2024-03-07
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-03-07
K200 · Egress Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2024-05-17
D · Potential for more than minimal harm
2024-03-07
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-05-17
D · Potential for more than minimal harm
2022-11-21
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2023-02-04
D · Potential for more than minimal harm
2022-11-21
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-02-04
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-11-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-11-25
D · Potential for more than minimal harm
2025-05-01
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 2025-05-21
D · Potential for more than minimal harm
2025-05-01
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-05-21
D · Potential for more than minimal harm
2025-05-01
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 2025-05-21
D · Potential for more than minimal harm
2025-05-01
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2025-05-21
D · Potential for more than minimal harm
2025-05-01
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-21
E · Potential for more than minimal harm
2024-03-07
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2024-03-29
E · Potential for more than minimal harm
2024-03-07
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2024-03-29
E · Potential for more than minimal harm
2024-03-07
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-03-29
E · Potential for more than minimal harm
2024-03-07
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2024-03-29
D · Potential for more than minimal harm
2024-03-07
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2024-03-29
D · Potential for more than minimal harm
2024-03-07
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 2024-03-29
B · Minimal harm
2024-03-07
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 2024-03-29
F · Potential for more than minimal harm
2022-11-21
F803 · Nutrition and Dietary Deficiencies
Health
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
Corrected 2023-01-05
F · Potential for more than minimal harm
2022-11-21
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 2023-01-05
F · Potential for more than minimal harm
2022-11-21
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-01-05
F · Potential for more than minimal harm
2022-11-21
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-01-05
E · Potential for more than minimal harm
2022-11-21
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-01-05
E · Potential for more than minimal harm
2022-11-21
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 2023-01-05
E · Potential for more than minimal harm
2022-11-21
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-01-05
D · Potential for more than minimal harm
2022-11-21
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 2023-01-05
D · Potential for more than minimal harm
2022-11-21
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-01-05
D · Potential for more than minimal harm
2022-11-21
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-01-05
D · Potential for more than minimal harm
2022-11-21
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-01-05
D · Potential for more than minimal harm
2022-11-21
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-01-05
D · Potential for more than minimal harm
2022-11-21
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 2023-01-05
D · Potential for more than minimal harm
2022-11-21
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-01-05
D · Potential for more than minimal harm
2022-11-21
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2023-01-05
B · Minimal harm
2022-11-21
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2022-12-23
B · Minimal harm
2022-11-21
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 2022-12-22
B · Minimal harm
2022-11-21
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-12-22
Penalties and ownership
What sits behind the stars
Ownership
Long Term Care Management Services LLC
5% Or Greater Direct Ownership Interest · Organization
Mcneill, John
5% Or Greater Indirect Ownership Interest · Individual
Mcneill, Ronald
5% Or Greater Indirect Ownership Interest · Individual
Calcutt, Joeseph V
Operational/Managerial Control · Individual
Calcutt, Joeseph V
Corporate Officer · Individual
Long Term Care Management Services LLC
Operational/Managerial Control · Organization
Mcneill, John
Operational/Managerial Control · Individual
Mcneill, Ronald
Operational/Managerial Control · Individual
Miller, Robert
Corporate Director · Individual
Peters, Danielle
Operational/Managerial Control · Individual
Peterson, Gajarah
Operational/Managerial Control · Individual
Wilson, Jeffrey
Operational/Managerial Control · Individual
Nearby options
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#3
Trinity Grove
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3-star overall rating with 2-star inspections with abuse icon flag with $137,770 in total fines with 5 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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