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Liberty Commons Nursing & Rehab Center of Southpor
630 Fodale Avenue, Southport, NC 28461 · CMS Certification Number (CCN) 345373
At a glance
- CMS overall rating
- ★★★☆☆ 3 of 5
- Health inspection citations
- 31 in the last 3 inspection cycles (0 immediate jeopardy, 0 actual harm, 2 from complaints)
- Fire safety citations
- 8
- Fines (last 3 years)
- 0 fines, total $0
- Payment denials
- 0
- Most recent standard inspection
- May 1, 2025
- Official record
- Medicare Care Compare page for this facility
Source: CMS Nursing Home Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
CMS star ratings
CMS rates every Medicare- and Medicaid-certified nursing home from 1 to 5 stars. Health inspection stars are relative to other homes in the same state: the top 10% get 5 stars and the bottom 20% get 1 star. CMS says to use the ratings together with other information, including a visit. Technical Users’ Guide
| Rating | This facility | North Carolina average | U.S. average |
|---|---|---|---|
| Overall | ★★★☆☆ 3 of 5 | 2.9 | 3 |
| Health inspections | ★★★☆☆ 3 of 5 | 2.9 | 2.8 |
| Staffing | ★★★☆☆ 3 of 5 | 2.7 | 2.9 |
| Quality measures | ★★☆☆☆ 2 of 5 | 3.3 | 3.6 |
| Long-stay quality | ★★★☆☆ 3 of 5 | Not published | Not published |
| Short-stay quality | ★★☆☆☆ 2 of 5 | Not published | Not published |
Averages: CMS State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Health inspections
| Inspection cycle | Standard survey date | Health citations | From standard survey | From complaints |
|---|---|---|---|---|
| Cycle 1 (most recent) | May 1, 2025 | 6 | 5 | 2 |
| Cycle 2 | March 7, 2024 | 7 | 7 | 0 |
CMS weighted health inspection score: 28 (lower is better; it counts citation severity, complaints and repeat revisits). Citations from infection control inspections: Not published. How to read these citations
31 health citations across 4 inspection dates, newest first. The letter is CMS’s scope/severity code: A–C means potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, and J–L immediate jeopardy.
November 19, 2025: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 11/25/2025 |
May 1, 2025: 5 citations (Standard + Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Standard | Deficient, Provider has date of correction Corrected 05/21/2025 |
| D | F-0770 | Provide timely, quality laboratory services/tests to meet the needs of residents. Administration Deficiencies | Standard | Deficient, Provider has date of correction Corrected 05/21/2025 |
| D | F-0727 | 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. Nursing and Physician Services Deficiencies | Standard | Deficient, Provider has date of correction Corrected 05/21/2025 |
| D | F-0658 | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 05/21/2025 |
| D | F-0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 05/21/2025 |
March 7, 2024: 7 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0867 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Administration Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/29/2024 |
| D | F-0761 | 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. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/29/2024 |
| E | F-0760 | Ensure that residents are free from significant medication errors. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/29/2024 |
| E | F-0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/29/2024 |
| D | F-0685 | Assist a resident in gaining access to vision and hearing services. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/29/2024 |
| B | F-0636 | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has plan of correction Corrected 03/29/2024 |
| E | F-0561 | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 03/29/2024 |
November 21, 2022: 18 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| F | F-0908 | Keep all essential equipment working safely. Environmental Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/05/2023 |
| E | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/05/2023 |
| F | F-0867 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Administration Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/05/2023 |
| F | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/05/2023 |
| D | F-0806 | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/05/2023 |
| F | F-0803 | 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. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/05/2023 |
| E | F-0761 | 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. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/05/2023 |
| D | F-0757 | Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/05/2023 |
| D | F-0756 | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/05/2023 |
| D | F-0726 | 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. Nursing and Physician Services Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/05/2023 |
| D | F-0692 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/05/2023 |
| E | F-0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/05/2023 |
| D | F-0688 | 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. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/05/2023 |
| B | F-0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has plan of correction Corrected 12/22/2022 |
| B | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has plan of correction Corrected 12/22/2022 |
| B | F-0655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has plan of correction Corrected 12/23/2022 |
| D | F-0641 | Ensure each resident receives an accurate assessment. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/05/2023 |
| D | F-0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 01/05/2023 |
Source: CMS Health Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Fire safety inspections
8 fire safety citations across 3 inspection dates
| Date | Severity | Tag | What was cited | Status |
|---|---|---|---|---|
| 05/01/2025 | D | K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 07/12/2025 |
| 05/01/2025 | D | K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 07/12/2025 |
| 05/01/2025 | D | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 07/12/2025 |
| 03/07/2024 | F | K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 05/17/2024 |
| 03/07/2024 | D | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 05/17/2024 |
| 03/07/2024 | D | K-0200 | Meet other general requirements. Egress Deficiencies | Deficient, Provider has date of correction Corrected 05/17/2024 |
| 11/21/2022 | D | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies | Deficient, Provider has date of correction Corrected 02/04/2023 |
| 11/21/2022 | D | K-0161 | Use approved construction type or materials. Construction Deficiencies | Deficient, Provider has date of correction Corrected 02/04/2023 |
Automatic sprinklers in all required areas: Yes. CMS does not count fire safety citations in the health inspection star rating.
Source: CMS Fire Safety Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Penalties
No fines or payment denials published for this facility in the CMS Penalties file (last 3 years).
Source: CMS Penalties: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Staffing
| Measure | This facility | North Carolina average | U.S. average |
|---|---|---|---|
| Total nurse staff hours per resident per day | 3.58 | 3.85 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.68 | 0.62 | 0.69 |
| LPN/LVN hours per resident per day | 0.96 | Not published | Not published |
| Nurse aide hours per resident per day | 1.95 | Not published | Not published |
| Total nurse staff hours per resident per day, weekends | 3.34 | Not published | Not published |
| RN hours per resident per day, weekends | 0.53 | Not published | Not published |
| Total nursing staff turnover (%) | Staffing data did not meet the criteria required to calculate a turnover measure. | 49 | 45.8 |
| Registered nurse turnover (%) | Staffing data did not meet the criteria required to calculate a turnover measure. | Not published | Not published |
| Administrators who have left | Staffing data did not meet the criteria required to calculate a turnover measure. | Not published | Not published |
Reported hours come from the Payroll-Based Journal (PBJ) staffing data that facilities submit to CMS each quarter.
Source: CMS Provider Information; State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Facility details
- Legal business name
- Liberty Healthcare Group LLC
- Ownership type
- For profit - Limited Liability company
- Chain
- Liberty Senior Living (37 facilities)
- Ownership changed in last 12 months
- No
- Certified beds
- 99
- Average residents per day
- 79.3
- Participates in
- Medicare and Medicaid
- Located inside a hospital
- No
- Continuing care retirement community
- No
- Resident and family council
- Resident
- First approved for Medicare/Medicaid
- May 31, 1991
- County/parish
- Brunswick
Source: CMS Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Owners and managers reported to CMS
27 ownership and management records
| Name | Role | Type | Ownership % | Since |
|---|---|---|---|---|
| LONG TERM CARE MANAGEMENT SERVICES LLC | 5% OR GREATER DIRECT OWNERSHIP INTEREST | Organization | 100% | undefined undefined, NaN |
| LIBERTY LONG TERM CARE LLC | DIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| JOHN A MCNEILL JR 2012 IRRV TR | INDIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| LIBERTY HEALTHCARE GROUP LLC | INDIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| OCEAN TRAIL CONVALESCENT CENTER INC. | INDIRECT OWNERSHIP INTEREST | Organization | NOT APPLICABLE | undefined undefined, NaN |
| MCNEILL, JOHN | INDIRECT OWNERSHIP INTEREST | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MILLER, ROBERT | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| CALCUTT, JOSEPH | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| LONG TERM CARE MANAGEMENT SERVICES LLC | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| CALCUTT, JOSEPH | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MCNEILL, JOHN | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MCNEILL, RONALD | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| PETERS, DANIELLE | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| PETERSON, GAJARAH | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| WILSON, JEFFREY | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| WILSON, JEFFREY | INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MCNEILL, ROBERT | TRUSTEE OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| JOHN A MCNEILL JR 2012 IRRV TR | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| LIBERTY HEALTHCARE GROUP LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| LIBERTY HEALTHCARE MANAGEMENT INC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| LIBERTY LONG TERM CARE LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| LONG TERM CARE MANAGEMENT SERVICES LLC | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| OCEAN TRAIL CONVALESCENT CENTER INC. | ADP OF THE SNF | Organization | NOT APPLICABLE | undefined undefined, NaN |
| BROWN, NOLAN | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| CALCUTT, JOSEPH | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MILLER, ROBERT | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
| WILSON, JEFFREY | ADP OF THE SNF | Individual | NOT APPLICABLE | undefined undefined, NaN |
Source: CMS Ownership: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Check it yourself
- Medicare Care Compare: Liberty Commons Nursing & Rehab Center of Southpor. Full inspection reports, quality measures and staffing.
- DHSR Complaint Intake Unit: File a Complaint. The state agency also takes nursing home complaints.
- Ask the facility to show you its most recent inspection report and plan of correction.
Page built from CMS data files processed September 1, 2026 (CMS refreshes monthly). Last checked October 26, 2026. Not a ranking or endorsement.