Cycle 1
Health 2024-12-19 · Fire 2024-12-19
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Whiteville, NC
Shoreland Health Care and Retirement Center Inc
4-star overall rating with 5-star inspections with $5,077 in total fines with 1 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
200 Flower-Pridgen Drive, Whiteville, NC
(910) 642-4300
Overall
4 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
2 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
89
Certified beds
Average residents
86
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Liberty Senior Living
Operator or chain grouping
Approved since
1991-09-10
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
0.30
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.90
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.22
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.41
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.20
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.11
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.12
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.31
CMS adjusted RN staffing hours
Adjusted total hours
3.45
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
70%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,186
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.48
Composite VBP score used to determine payment impact.
Payment multiplier
0.9860
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
6.65
Baseline 17.60% · Performance 18.35% · Measure score 6.65 · Achievement 6.65 · Improvement 0
Healthcare-associated infections
1.33
Baseline 7.10% · Performance 7.44% · Measure score 1.33 · Achievement 1.33 · Improvement 0
Total nurse turnover
3.71
Baseline 53.23% · Performance 48.53% · Measure score 3.71 · Achievement 3.71 · Improvement 1.16
Adjusted total nurse staffing
0.51
Baseline 2.92 hours · Performance 3.21 hours · Measure score 0.51 · Achievement 0 · Improvement 0.51
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.51% |
10.72%
0.2 pts better
|
No Different than the National Rate · Eligible stays 113 · Observed rate 10.62% · Lower 95% interval 7.43% |
| Discharge to community | 60.51% |
50.57%
9.9 pts better
|
Better than the National Rate · Eligible stays 119 · Observed rate 56.3% · Lower 95% interval 51.99% |
| Medicare spending per beneficiary | 1.09 |
1.02
0.1 pts worse
|
|
| Drug regimen review with follow-up | 88.89% |
95.27%
6.4 pts worse
|
Numerator 72 · Denominator 81 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 81 |
| Discharge self-care score | 61.29% |
53.69%
7.6 pts better
|
Numerator 38 · Denominator 62 |
| Discharge mobility score | 53.23% |
50.94%
2.3 pts better
|
Numerator 33 · Denominator 62 |
| Pressure ulcers or injuries, new or worsened | 6.17% |
2.29%
3.9 pts worse
|
Numerator 5 · Denominator 81 · Adjusted rate 4.42% |
| Healthcare-associated infections requiring hospitalization | 7.44% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 82 · Observed rate 8.54% · Lower 95% interval 4.41% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 90 |
| Staff flu vaccination coverage | 5.88% |
42%
36.1 pts worse
|
Numerator 6 · Denominator 102 |
| Discharge function score | 53.23% |
56.45%
3.2 pts worse
|
Numerator 33 · Denominator 62 |
| Transfer of health information to provider | 75% |
95.95%
21 pts worse
|
Numerator 18 · Denominator 24 |
| Transfer of health information to patient | 80.49% |
96.28%
15.8 pts worse
|
Numerator 33 · Denominator 41 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 32 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.1% |
91.5%
6.6 pts better
|
93.4%
4.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 96.9% · Q3 97.0% · Q4 98.6% · 4Q avg 98.1% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 94.3% |
94.1%
0.2 pts better
|
95.5%
1.2 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 94.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.0% |
3.6%
0.6 pts better
|
3.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.1% · Q2 4.6% · Q3 1.5% · Q4 1.4% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.6% |
4.8%
3.2 pts better
|
11.4%
9.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.8% · Q3 1.5% · Q4 0.0% · 4Q avg 1.6% |
| Percentage of long-stay residents who lose too much weight | 9.0% |
7.2%
1.8 pts worse
|
5.4%
3.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 7.8% · Q3 9.4% · Q4 10.3% · 4Q avg 9.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.9% |
21.6%
1.7 pts better
|
19.6%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.7% · Q2 25.0% · Q3 22.6% · Q4 15.5% · 4Q avg 19.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 7.5% |
15.0%
7.5 pts better
|
16.7%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 11.1% · Q2 6.0% · Q3 7.7% · Q4 5.6% · 4Q avg 7.5% · 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 | 58.1% |
21.5%
36.6 pts worse
|
16.3%
41.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 58.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.8% |
16.8%
2 pts worse
|
14.9%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.6% · Q2 17.0% · Q3 25.0% · Q4 20.8% · 4Q avg 18.8% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.7% |
0.9%
0.8 pts worse
|
1.0%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 1.9% · Q3 2.6% · Q4 0.7% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 8.4% |
2.6%
5.8 pts worse
|
1.7%
6.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.3% · Q2 4.7% · Q3 7.5% · Q4 6.8% · 4Q avg 8.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 26.2% |
21.2%
5 pts worse
|
19.8%
6.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.5% · Q2 19.5% · Q3 20.5% · Q4 29.8% · 4Q avg 26.2% |
| Percentage of long-stay residents with pressure ulcers | 8.3% |
6.0%
2.3 pts worse
|
5.1%
3.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.6% · Q2 10.1% · Q3 7.4% · Q4 5.7% · 4Q avg 8.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
79.9%
19.3 pts better
|
81.7%
17.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.0% · Q2 100.0% · Q3 98.9% · Q4 98.8% · 4Q avg 99.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 25.4% |
13.2%
12.2 pts worse
|
12.0%
13.4 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.4% · Observed 25.0% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.5%
0.3 pts better
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 1.7% · Q4 2.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.8% |
78.1%
9.7 pts better
|
79.7%
8.1 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.8% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 15.9% |
22.9%
7 pts better
|
23.9%
8 pts better
|
Short Stay · 20240701-20250630 · Adjusted 15.9% · Observed 17.2% · Expected 25.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-19 · Fire 2023-10-19
5 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Cycle 3
Health 2022-06-24 · Fire 2022-06-24
5 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
1 fire-safety deficiencies
Top issue: Construction (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-19
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-03-29
F · Potential for more than minimal harm
2024-12-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-29
D · Potential for more than minimal harm
2024-12-19
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 2025-03-29
D · Potential for more than minimal harm
2024-12-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-03-29
D · Potential for more than minimal harm
2024-12-19
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2025-03-29
D · Potential for more than minimal harm
2023-10-19
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-12-06
D · Potential for more than minimal harm
2023-10-19
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-12-06
D · Potential for more than minimal harm
2023-10-19
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2023-12-06
D · Potential for more than minimal harm
2022-06-24
K100 · Construction Deficiencies
Fire Safety
Meet other general requirements.
Corrected 2022-08-17
Inspection history
Recent health citations
D · Potential for more than minimal harm
2024-12-19
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 2024-11-15
D · Potential for more than minimal harm
2023-10-19
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 2023-11-06
D · Potential for more than minimal harm
2023-10-19
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-11-06
B · Minimal harm
2023-10-19
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 2023-11-06
B · Minimal harm
2023-10-19
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2023-11-06
B · Minimal harm
2023-10-19
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-11-06
F · Potential for more than minimal harm
2022-06-24
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-08-05
E · Potential for more than minimal harm
2022-06-24
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 2022-08-05
E · Potential for more than minimal harm
2022-06-24
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2022-08-05
E · Potential for more than minimal harm
2022-06-24
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2022-07-29
E · Potential for more than minimal harm
2022-06-24
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 2022-08-05
Penalties and ownership
What sits behind the stars
$5,077
2024-12-19
Fine
Fine · fine $5,077
Fine
Ownership
Calcutt, Joeseph V
W-2 Managing Employee · Individual
Liberty Healthcare Management Inc
Operational/Managerial Control · Organization
Mcneill, John
5% Or Greater Direct Ownership Interest · Individual
Mcneill, John
Corporate Director · Individual
Mcneill, John
Corporate Officer · Individual
Mcneill, Ronald
5% Or Greater Direct Ownership Interest · Individual
Mcneill, Ronald
Corporate Director · Individual
Mcneill, Ronald
Corporate Officer · Individual
Miller, Robert
Corporate Director · Individual
Wilson, Jeffrey
Corporate Director · Individual
Wilson, Jeffrey
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Liberty Commons Nursing and Rehabilitation Center
Whiteville, NC
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
#2
Premier Living and Rehab Center
Lake Waccamaw, NC
1-star overall rating with 1-star inspections with Special Focus status with abuse icon flag with $381,817 in total fines with 20 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Bladen East Health And Rehab
Elizabethtown, NC
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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