Cycle 1
Health 2025-01-24 · Fire 2025-01-24
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Clinton, NC
Southwood Nursing and Retirement
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
180 Southwood Drive, Clinton, NC
(910) 592-8165
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
100
Certified beds
Average residents
85
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Liberty Senior Living
Operator or chain grouping
Approved since
1995-04-17
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
0.21
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.88
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
3.32
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.09
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.14
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
0.03
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.22
CMS adjusted RN staffing hours
Adjusted total hours
3.41
CMS adjusted total nurse staffing hours
Case-mix index
1.33
Higher values indicate more complex resident acuity
RN turnover
57%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
59%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,671
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
1.93
Composite VBP score used to determine payment impact.
Payment multiplier
0.9804
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 17.52% · Performance 22.04% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.63% · Performance 8.91% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
0.77
Baseline 52.63% · Performance 60.53% · Measure score 0.77 · Achievement 0.77 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.48 hours · Performance 3.16 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.61% |
10.72%
1.9 pts worse
|
No Different than the National Rate · Eligible stays 129 · Observed rate 16.28% · Lower 95% interval 8.76% |
| Discharge to community | 49.58% |
50.57%
1 pts worse
|
No Different than the National Rate · Eligible stays 127 · Observed rate 43.31% · Lower 95% interval 40.82% |
| Medicare spending per beneficiary | 1.02 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 64 · Denominator 64 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 64 |
| Discharge self-care score | 58.33% |
53.69%
4.6 pts better
|
Numerator 28 · Denominator 48 |
| Discharge mobility score | 62.5% |
50.94%
11.6 pts better
|
Numerator 30 · Denominator 48 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 64 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 8.91% |
7.12%
1.8 pts worse
|
No Different than the National Rate · Eligible stays 79 · Observed rate 11.39% · Lower 95% interval 5.05% |
| Staff COVID-19 vaccination coverage | 1.92% |
8.2%
6.3 pts worse
|
Numerator 1 · Denominator 52 |
| Staff flu vaccination coverage | 40.45% |
42%
1.5 pts worse
|
Numerator 36 · Denominator 89 |
| Discharge function score | 54.17% |
56.45%
2.3 pts worse
|
Numerator 26 · Denominator 48 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 49 · Denominator 49 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 26.09% |
25.2%
0.9 pts better
|
Numerator 6 · Denominator 23 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
91.5%
8.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.8% |
94.1%
4.7 pts better
|
95.5%
3.3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.8% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.4% |
3.6%
2.2 pts better
|
3.3%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 1.3% · Q3 1.4% · Q4 1.4% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.0% |
4.8%
0.8 pts better
|
11.4%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 4.1% · Q3 4.3% · Q4 0.0% · 4Q avg 4.0% |
| Percentage of long-stay residents who lose too much weight | 5.6% |
7.2%
1.6 pts better
|
5.4%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 8.1% · Q3 7.1% · Q4 6.5% · 4Q avg 5.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.5% |
21.6%
1.1 pts better
|
19.6%
0.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.4% · Q2 19.4% · Q3 19.6% · Q4 22.6% · 4Q avg 20.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 8.7% |
15.0%
6.3 pts better
|
16.7%
8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.5% · Q2 9.6% · Q3 6.4% · Q4 10.0% · 4Q avg 8.7% · 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 | 6.8% |
21.5%
14.7 pts better
|
16.3%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 9.1% · 4Q avg 6.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.5% |
16.8%
9.3 pts better
|
14.9%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 11.1% · Q3 4.2% · Q4 11.3% · 4Q avg 7.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.4% |
0.9%
1.5 pts worse
|
1.0%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 4.6% · Q3 1.2% · Q4 0.9% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.7% |
2.6%
1.9 pts better
|
1.7%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 1.4% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 28.4% |
21.2%
7.2 pts worse
|
19.8%
8.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.2% · Q2 22.4% · Q3 32.1% · Q4 25.5% · 4Q avg 28.4% |
| Percentage of long-stay residents with pressure ulcers | 9.3% |
6.0%
3.3 pts worse
|
5.1%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 9.3% · Q3 8.9% · Q4 12.0% · 4Q avg 9.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 97.5% |
79.9%
17.6 pts better
|
81.7%
15.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.0% · Q2 98.8% · Q3 97.1% · Q4 97.3% · 4Q avg 97.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 25.1% |
13.2%
11.9 pts worse
|
12.0%
13.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.1% · Observed 23.9% · Expected 10.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.7% |
78.1%
19.6 pts better
|
79.7%
18 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 97.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.0% |
22.9%
1.1 pts worse
|
23.9%
0.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.0% · Observed 23.9% · Expected 23.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-04 · Fire 2024-01-04
4 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
12 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Cycle 3
Health 2022-09-08 · Fire 2022-09-08
4 health deficiencies
Top issue: Infection Control (1 deficiency)
3 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-01-24
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-02-28
F · Potential for more than minimal harm
2024-01-04
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-04-12
F · Potential for more than minimal harm
2024-01-04
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-04-12
F · Potential for more than minimal harm
2024-01-04
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-04-12
F · Potential for more than minimal harm
2024-01-04
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-04-12
E · Potential for more than minimal harm
2024-01-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-01-04
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-01-04
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-01-04
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-01-04
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-01-04
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-01-04
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-04-12
D · Potential for more than minimal harm
2024-01-04
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-04-12
F · Potential for more than minimal harm
2022-09-08
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2022-11-25
F · Potential for more than minimal harm
2022-09-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-11-25
D · Potential for more than minimal harm
2022-09-08
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2022-11-25
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-01-24
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-02-11
D · Potential for more than minimal harm
2025-01-24
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-02-11
D · Potential for more than minimal harm
2025-01-24
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 2025-02-11
G · Actual harm
2024-07-01
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 2024-06-03
G · Actual harm
2024-07-01
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 2024-07-02
D · Potential for more than minimal harm
2024-01-04
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 2024-01-10
F · Potential for more than minimal harm
2022-09-08
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 2022-10-06
F · Potential for more than minimal harm
2022-09-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2022-10-06
D · Potential for more than minimal harm
2022-09-08
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2022-10-06
D · Potential for more than minimal harm
2022-09-08
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 2022-10-06
Penalties and ownership
What sits behind the stars
$4,256
2024-07-01
Fine
Fine · fine $4,256
Fine
$4,256
2024-07-01
Fine
Fine · fine $4,256
Fine
Ownership
Calcutt, Joeseph V
Corporate Officer · Individual
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
Liberty Healthcare Services Of Southwood Nursing Center, LLC
5% Or Greater Direct Ownership Interest · Organization
Liberty Long Term Care LLC
5% Or Greater Direct Ownership Interest · Organization
Long Term Care Management Services LLC
5% Or Greater Direct 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 Officer · Individual
Miller, Robert
Corporate Director · Individual
Ronald B And Cynthia J Mcneill 2013 Irrv Tr
5% Or Greater Indirect Ownership Interest · Organization
Wilson, Jeffrey
Corporate Officer · Individual
Wilson, Robert
Operational/Managerial Control · Individual
Nearby options
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#2
Warsaw Rehabilitation and Healthcare Center
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#3
Kenansville Rehabilitation and Healthcare Center
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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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