Cycle 1
Health 2025-08-14 · Fire 2024-08-12
9 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Clinton, NC
Mary Gran Nursing Center
1-star overall rating with 1-star inspections with abuse icon flag with $68,172 in total fines with 9 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
120 Southwood Drive, Clinton, NC
(910) 592-7981
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
212
Certified beds
Average residents
108
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
0.35
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.95
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.37
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.67
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.30
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.41
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.22
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.33
CMS adjusted RN staffing hours
Adjusted total hours
3.55
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
29%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
40%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,553
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
19.98
Composite VBP score used to determine payment impact.
Payment multiplier
0.9823
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.69
Baseline 20.57% · Performance 21.11% · Measure score 0.69 · Achievement 0.69 · Improvement 0
Healthcare-associated infections
1.08
Baseline 7.28% · Performance 7.51% · Measure score 1.08 · Achievement 1.08 · Improvement 0
Total nurse turnover
6.22
Baseline 57.30% · Performance 38.27% · Measure score 6.22 · Achievement 6.22 · Improvement 5.36
Adjusted total nurse staffing
0
Baseline 3.06 hours · Performance 3.10 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.3% |
10.72%
1.6 pts worse
|
No Different than the National Rate · Eligible stays 112 · Observed rate 14.29% · Lower 95% interval 8.49% |
| Discharge to community | 55.53% |
50.57%
5 pts better
|
No Different than the National Rate · Eligible stays 115 · Observed rate 53.04% · Lower 95% interval 45.39% |
| Medicare spending per beneficiary | 0.89 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 59 · Denominator 59 |
| Falls with major injury | 1.69% |
0.77%
0.9 pts worse
|
Numerator 1 · Denominator 59 |
| Discharge self-care score | 51.22% |
53.69%
2.5 pts worse
|
Numerator 21 · Denominator 41 |
| Discharge mobility score | 60.98% |
50.94%
10 pts better
|
Numerator 25 · Denominator 41 |
| Pressure ulcers or injuries, new or worsened | 1.69% |
2.29%
0.6 pts better
|
Numerator 1 · Denominator 59 · Adjusted rate 1.68% |
| Healthcare-associated infections requiring hospitalization | 7.51% |
7.12%
0.4 pts worse
|
No Different than the National Rate · Eligible stays 68 · Observed rate 7.35% · Lower 95% interval 4.09% |
| Staff COVID-19 vaccination coverage | 9.38% |
8.2%
1.2 pts better
|
Numerator 12 · Denominator 128 |
| Staff flu vaccination coverage | 34.53% |
42%
7.5 pts worse
|
Numerator 48 · Denominator 139 |
| Discharge function score | 53.66% |
56.45%
2.8 pts worse
|
Numerator 22 · Denominator 41 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 33 · Denominator 33 |
| Resident COVID-19 vaccinations up to date | 11.11% |
25.2%
14.1 pts worse
|
Numerator 3 · Denominator 27 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
1.8
0.4 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 1.7 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 3.1 |
1.8
1.3 pts worse
|
1.8
1.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.1 · Observed 2.5 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
91.5%
8.3 pts better
|
93.4%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.1% · Q3 100.0% · Q4 100.0% · 4Q avg 99.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.1%
5.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.0% |
3.6%
1.6 pts better
|
3.3%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 2.6% · Q3 1.0% · Q4 2.0% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.5% |
4.8%
4.3 pts better
|
11.4%
10.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.9% · Q3 0.0% · Q4 0.0% · 4Q avg 0.5% |
| Percentage of long-stay residents who lose too much weight | 2.8% |
7.2%
4.4 pts better
|
5.4%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.1% · Q3 5.0% · Q4 3.7% · 4Q avg 2.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.0% |
21.6%
4.6 pts better
|
19.6%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.9% · Q2 19.6% · Q3 16.2% · Q4 15.9% · 4Q avg 17.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 16.9% |
15.0%
1.9 pts worse
|
16.7%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 14.3% · Q3 16.9% · Q4 20.6% · 4Q avg 16.9% · 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 | 14.3% |
21.5%
7.2 pts better
|
16.3%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 15.9% · Q4 3.9% · 4Q avg 14.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 6.6% |
16.8%
10.2 pts better
|
14.9%
8.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 9.8% · Q3 7.0% · Q4 4.1% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.6% |
0.9%
1.7 pts worse
|
1.0%
1.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 3.5% · Q3 4.5% · Q4 0.7% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 8.0% |
2.6%
5.4 pts worse
|
1.7%
6.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 9.3% · Q2 6.1% · Q3 9.0% · Q4 8.1% · 4Q avg 8.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.1% |
21.2%
3.9 pts worse
|
19.8%
5.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 22.7% · Q2 26.2% · Q3 22.3% · Q4 28.7% · 4Q avg 25.1% |
| Percentage of long-stay residents with pressure ulcers | 7.4% |
6.0%
1.4 pts worse
|
5.1%
2.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 7.8% · Q3 8.0% · Q4 7.9% · 4Q avg 7.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 93.4% |
79.9%
13.5 pts better
|
81.7%
11.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.5% · Q2 93.0% · Q3 94.3% · Q4 90.2% · 4Q avg 93.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.5% |
13.2%
0.3 pts worse
|
12.0%
1.5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.5% · Observed 13.0% · Expected 10.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.9% |
1.5%
0.6 pts better
|
1.6%
0.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 0.0% · Q4 1.8% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 92.0% |
78.1%
13.9 pts better
|
79.7%
12.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 92.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.2% |
22.9%
0.7 pts better
|
23.9%
1.7 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.2% · Observed 20.3% · Expected 21.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-12 · Fire 2023-03-23
2 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Cycle 3
Health 2023-03-23 · Fire 2022-02-17
16 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
1 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-08-12
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-12-22
E · Potential for more than minimal harm
2024-08-12
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-12-22
D · Potential for more than minimal harm
2024-08-12
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2024-12-22
D · Potential for more than minimal harm
2024-08-12
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-12-22
D · Potential for more than minimal harm
2024-08-12
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 2024-12-22
D · Potential for more than minimal harm
2024-08-12
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-12-22
D · Potential for more than minimal harm
2024-08-12
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-12-22
D · Potential for more than minimal harm
2024-08-12
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-12-22
F · Potential for more than minimal harm
2023-03-23
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-07-23
F · Potential for more than minimal harm
2023-03-23
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-07-23
F · Potential for more than minimal harm
2023-03-23
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 2023-07-23
F · Potential for more than minimal harm
2023-03-23
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-07-23
F · Potential for more than minimal harm
2023-03-23
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-07-23
F · Potential for more than minimal harm
2023-03-23
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-07-23
D · Potential for more than minimal harm
2023-03-23
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-07-23
D · Potential for more than minimal harm
2023-03-23
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-07-23
F · Potential for more than minimal harm
2022-02-17
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-04-08
Inspection history
Recent health citations
J · Immediate jeopardy
2025-08-14
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 2025-09-01
J · Immediate jeopardy
2025-08-14
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-09-01
J · Immediate jeopardy
2025-08-14
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-09-01
J · Immediate jeopardy
2025-08-14
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 2025-09-01
G · Actual harm
2025-08-14
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 2025-09-01
E · Potential for more than minimal harm
2025-08-14
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 2025-09-01
D · Potential for more than minimal harm
2025-08-14
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-09-01
D · Potential for more than minimal harm
2025-08-14
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 2025-09-01
E · Potential for more than minimal harm
2025-03-17
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-04-08
F · Potential for more than minimal harm
2024-08-12
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 2024-08-23
E · Potential for more than minimal harm
2024-08-12
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2024-08-23
E · Potential for more than minimal harm
2023-03-23
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-04-28
E · Potential for more than minimal harm
2023-03-23
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 2023-04-28
E · Potential for more than minimal harm
2023-03-23
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-04-28
E · Potential for more than minimal harm
2023-03-23
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-04-28
E · Potential for more than minimal harm
2023-03-23
F810 · Nutrition and Dietary Deficiencies
Health
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected 2023-04-28
E · Potential for more than minimal harm
2023-03-23
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 2023-04-28
D · Potential for more than minimal harm
2023-03-23
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 2023-04-28
D · Potential for more than minimal harm
2023-03-23
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 2023-04-28
D · Potential for more than minimal harm
2023-03-23
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-03-23
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-03-23
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-03-23
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-03-23
F848 · Administration Deficiencies
Health
Provide a neutral and fair arbitration process and agree to arbitrator and venue.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-03-23
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-04-28
D · Potential for more than minimal harm
2023-03-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-28
C · Minimal harm
2023-03-23
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-04-28
Penalties and ownership
What sits behind the stars
$68,172
2025-08-14
Fine
Fine · fine $68,172
Fine
Ownership
Liberty Long Term Care LLC
5% Or Greater Direct Ownership Interest · Organization
John A Mcneill Jr 2012 Irrv Tr
5% Or Greater Indirect Ownership Interest · Organization
Liberty Healthcare Group LLC
5% Or Greater Indirect Ownership Interest · Organization
Mcneill, John
5% Or Greater Indirect Ownership Interest · Individual
Mcneill, John
Corporate Director · Individual
Mcneill, Ronald
5% Or Greater Indirect Ownership Interest · Individual
Mcneill, Ronald
Corporate Director · Individual
Ronald B And Cynthia J Mcneill 2013 Irrv Tr
5% Or Greater Indirect Ownership Interest · Organization
Spell, Marilynn
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Southwood Nursing and Retirement
Clinton, NC
3-star overall rating with 4-star inspections with $8,512 in total fines with 2 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Warsaw Rehabilitation and Healthcare Center
Warsaw, NC
1-star overall rating with 2-star inspections with abuse icon flag with $43,924 in total fines with 7 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Kenansville Rehabilitation and Healthcare Center
Kenansville, NC
4-star overall rating with 5-star inspections with 2 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
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