Liberty Commons Nursing & Rehab Center of Southpor

630 Fodale Avenue
Southport, NC, 28461
9104579581
CCN: 345373
3
Overall
3
Health
4
Staffing
4
Quality
ChainLIBERTY SENIOR LIVING
Special FocusAbuse IconOwnership Changed (12mo)Inspection OverdueOIG ExcludedUnder CIA
Ownership
NameRole%
LONG TERM CARE MANAGEMENT SERVICES LLC5% OR GREATER DIRECT OWNERSHIP INTEREST100%
MCNEILL, JOHN5% OR GREATER INDIRECT OWNERSHIP INTEREST50%
MCNEILL, RONALD5% OR GREATER INDIRECT OWNERSHIP INTEREST50%
MILLER, ROBERTCORPORATE DIRECTORNOT APPLICABLE
CALCUTT, JOESEPH VCORPORATE OFFICERNOT APPLICABLE
MCNEILL, JOHNOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
MCNEILL, RONALDOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
PETERS, DANIELLEOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
PETERSON, GAJARAHOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
WILSON, JEFFREYOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
CALCUTT, JOESEPH VOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
LONG TERM CARE MANAGEMENT SERVICES LLCOPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE
Health Deficiencies (31)
2025-11-19 · Health
D
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
2025-05-01 · Health
D
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
D
F770 · Administration Deficiencies
Provide timely, quality laboratory services/tests to meet the needs of residents.
D
F727 · Nursing and Physician Services Deficiencies
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.
D
F658 · Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
D
F580 · Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
2024-03-07 · Health
E
F867 · Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
D
F761 · Pharmacy Service Deficiencies
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.
E
F760 · Pharmacy Service Deficiencies
Ensure that residents are free from significant medication errors.
E
F757 · Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
D
F685 · Quality of Life and Care Deficiencies
Assist a resident in gaining access to vision and hearing services.
B
F636 · Resident Assessment and Care Planning Deficiencies
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
E
F561 · Resident Rights Deficiencies
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
2022-11-21 · Health
F
F908 · Environmental Deficiencies
Keep all essential equipment working safely.
E
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
F
F867 · Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
F
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
D
F806 · Nutrition and Dietary Deficiencies
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
F
F803 · Nutrition and Dietary Deficiencies
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.
E
F761 · Pharmacy Service Deficiencies
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.
D
F757 · Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
D
F756 · Pharmacy Service Deficiencies
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
D
F726 · Nursing and Physician Services Deficiencies
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.
D
F692 · Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
E
F690 · Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
D
F688 · Quality of Life and Care Deficiencies
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.
B
F657 · Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
B
F656 · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
B
F655 · Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
D
F641 · Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
D
F580 · Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Staffing
MetricThis FacilityNational Avg
Total Nurse Hrs/Resident/Day
3.72
3.68
RN Hrs/Resident/Day
0.68
0.54
LPN Hrs/Resident/Day
1.04
0.81
CNA Hrs/Resident/Day
2.00
2.33
PT Hrs/Resident/Day
0.08
0.12
Data as of 2026-03-01