Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Liberty Commons Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found expired medications and loose, unidentified pills in several medication carts and storage rooms. Staff interviews confirmed that expired medications and loose pills should not be present, and that established processes for checking medication storage were not being thoroughly followed.
Nursing staff failed to accurately document wound care treatments, medication administration, and assessment of an implanted device and dialysis shunt for three residents. Wound care and device monitoring were not consistently recorded on the TAR, and antihypertensive medication was documented as given when it had actually been held per physician order. Additionally, pressure dressing removal and site checks for a dialysis shunt were inaccurately documented, with staff confirming the tasks were not completed as recorded.
A resident with Alzheimer's disease, dementia, anorexia, and dysphagia was inaccurately coded in the MDS as having received daily IV or tube feeding fluids and routine antipsychotic medications, despite electronic records showing neither treatment was given during the assessment period. The MDS Coordinator confirmed the inaccuracy after reviewing the records, and the DON emphasized the importance of accurate MDS data entry.
A resident with multiple medical conditions was not weighed weekly as recommended by the RD and required by facility protocol. Despite clear care plan interventions and communication from the RD, staff failed to consistently document weekly weights, resulting in missed monitoring of the resident's nutritional status.
A resident who required dialysis did not receive safe and appropriate dialysis care and services, as the facility failed to ensure the necessary care was provided.
The facility failed to notify the physician of a resident's persistent symptoms indicative of C. difficile infection, leading to a delayed diagnosis. Additionally, another resident received insulin outside prescribed parameters without physician notification. Staff interviews revealed inconsistent communication and documentation practices.
A resident with a history of chronic kidney disease and muscle weakness experienced frequent loose stools during her stay at an LTC facility. Despite signs of C. difficile infection, the facility failed to conduct a comprehensive assessment or notify the Medical Director in a timely manner. Anti-diarrheal medications were administered, contrary to guidelines for C. difficile, and the facility's policy for diagnostic testing was not followed. The resident's symptoms persisted, leading to a positive C. difficile test after discharge.
The facility failed to schedule an RN for at least 8 consecutive hours on 12 days out of 122 reviewed, with resident census ranging from 75 to 88. The Administrator confirmed awareness of the issue and acknowledged non-compliance with regulatory requirements.
A Pharmacist Consultant failed to identify and report a medication error involving a resident with diabetes. The resident received Novolog Insulin despite orders to hold it if blood glucose was below 120 mg/dl. This occurred during drug regimen reviews in June and July, where the Pharmacist did not alert nursing staff about the error, leading to a deficiency.
A resident with type 2 diabetes received Novolog Insulin despite physician orders to hold it if blood glucose was below 120 mg/dl. This occurred six times over a month, as confirmed by Medication Administration Records and staff interviews. Nurse #1 administered the insulin at the resident's request, while Nurse #2 could not recall if she administered it or signed in error. The physician emphasized the importance of the order to prevent low blood sugar.
The facility failed to maintain infection control during medication administration and tube feeding care. A medication aide handled medications with bare hands, contrary to policy, and a nurse did not follow enhanced barrier precautions during a resident's bolus feeding. Despite training, these lapses occurred, highlighting issues in adherence to infection control protocols.
Expired Medications and Loose Pills Found in Medication Carts and Storage Rooms
Penalty
Summary
Surveyors observed that the facility failed to properly manage medication storage and labeling in multiple medication carts and storage rooms. Specifically, expired medications and loose, unidentified pills were found in three out of five medication carts and two out of three medication storage rooms. Examples included an expired inhaler, expired Vitamin C, expired promethazine suppositories, and expired simethicone tablets, as well as several loose pills of various shapes and colors in the drawers of the medication carts. These findings were confirmed during observations conducted in the presence of medication aides and nurses, all of whom acknowledged that expired medications and loose pills should not be present in the carts or storage rooms. Interviews with staff, including medication aides, nurses, and the DON, revealed that there was an established process for checking for expired medications, with responsibilities assigned to night shift nurses and unit managers. However, the presence of expired medications and loose pills indicated that these checks were not being performed thoroughly. Staff members consistently stated that expired medications and loose pills should not be present, and the DON acknowledged that the process was not being followed as intended.
Failure to Accurately Document Wound Care, Medication Administration, and Device Assessment
Penalty
Summary
The facility failed to maintain accurate and complete medical records for multiple residents, resulting in deficiencies related to documentation of wound care, medication administration, and assessment of medical devices. For one resident with a chronic unstageable sacral wound, nursing staff did not consistently document the administration of prescribed wound treatments on the Treatment Administration Record (TAR) or in the electronic medical record on several dates. Interviews with assigned nurses and the wound treatment nurse confirmed that wound care was performed but not properly documented, attributing the lapses to documentation errors. Additionally, the assessment of an implanted device for the same resident was inaccurately documented, with an agency nurse initially unaware of the device's presence but still signing off on the TAR as if the site had been monitored for infection. Another resident with an order for hydralazine, an antihypertensive medication, was affected by inaccurate documentation on the Medication Administration Record (MAR). The order specified that the medication should be held if the systolic blood pressure was less than 125 mmHg. However, the MAR showed the medication as administered on several occasions when, according to interviews with nursing staff and a medication aide, it had actually been held in accordance with the order. The staff acknowledged that these were documentation errors, as they had not accurately recorded when the medication was withheld. A third resident, who required hemodialysis and had an A/V dialysis shunt, experienced similar documentation issues. Physician orders required the removal of a pressure dressing over the shunt site 4-6 hours after returning from dialysis and for the site to be checked for bleeding, infection, bruit, and thrill. Nursing staff recorded on the MAR that they had removed the dressing and checked the site on specific dates, but interviews revealed that the dressing was not actually removed as ordered, and the documentation was inaccurate. The Assistant Director of Nursing also identified an error in the way the order was entered, which contributed to the confusion and subsequent documentation inaccuracies.
Inaccurate MDS Coding for Fluid Intake and Antipsychotic Use
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for one resident in the areas of daily fluid intake by intravenous (IV) or tube feeding and the use of antipsychotic medication. The resident, who had diagnoses including Alzheimer's disease, dementia, anorexia, and dysphagia, was documented in her quarterly MDS assessment as having received an average of 501 cc or more of fluids per day by IV or tube feeding and as having received antipsychotic medications on a routine basis during the look-back period. However, review of the resident's electronic Medication Administration Records (eMAR) for the relevant months showed that she had not received any antipsychotic medications or fluids by IV or tube feeding during that time. The MDS Coordinator confirmed, after reviewing the assessment and medical records, that the resident had not received these treatments during the look-back period and noted that a float nurse had completed the assessment. The Director of Nursing stated that data entered into the MDS should always be accurate.
Failure to Implement Weekly Weight Monitoring per Dietitian Recommendation
Penalty
Summary
The facility failed to implement a Registered Dietitian's recommendation to obtain weekly weights for a resident with chronic kidney disease, hypertension, and prostate cancer. The resident was admitted with orders for a cardiac diet and a mechanically altered diet. The care plan identified nutritional risks and included interventions such as monitoring for significant weight loss and following the Registered Dietitian's recommendations. Despite these interventions, the resident's electronic health record showed inconsistent and missing weekly weight documentation over several weeks following admission, contrary to both facility protocol and the Registered Dietitian's explicit instructions. Interviews with facility staff, including the MDS Coordinator, Registered Dietitian, Nurse Practitioner, and Assistant Director of Nursing, confirmed that weekly weights were expected for new admissions and that the responsibility for implementing the Registered Dietitian's recommendations rested with the MDS Coordinator and ADON. However, the staff were unable to explain why the weekly weights were not obtained as required, and the oversight resulted in a failure to monitor the resident's nutritional status as planned.
Failure to Provide Safe and Appropriate Dialysis Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate dialysis care and services for a resident who required such services. The report notes that the facility failed to ensure that the necessary dialysis care was provided to meet the resident's needs. Specific details about the actions or omissions that led to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Notify Physician of Resident Health Changes
Penalty
Summary
The facility failed to notify the physician when a resident exhibited signs of Clostridium Difficile (C. difficile) infection, including persistent loose, watery, mushy, and odorous stools. Despite the resident experiencing these symptoms from early February, the physician was only notified of the ongoing issue towards the end of the month, after a family member raised concerns. The resident was discharged and subsequently tested positive for C. difficile, highlighting a significant lapse in communication and monitoring by the facility staff. Additionally, the facility did not notify the physician when another resident received insulin outside the prescribed parameters. The resident was administered insulin despite blood sugar levels being below the threshold set by the physician, based on the resident's request. The nursing staff failed to communicate this deviation from the physician's orders, which could have allowed for adjustments to the treatment plan. Interviews with various staff members revealed a lack of consistent communication and documentation regarding the residents' conditions. Many staff members could not recall specific details about the residents or the actions taken, indicating a systemic issue in the facility's processes for monitoring and reporting significant changes in residents' health conditions.
Removal Plan
- The Director of Nursing met with all direct care nurses to initiate an assessment of 100% of current residents.
- The Registered Nurse Managers and Licensed Practical Support Nurses completed an audit of all residents for signs and symptoms of C. difficile.
- If a resident had 3 or more loose watery stools in 24 hours, the MD/Nurse Practitioner (NP)/PA will be notified for evaluation of C. difficile.
- If any residents were identified with any signs and symptoms of C. difficile, the medical record was reviewed to identify if the MD/NP/PA had been notified.
- A corrective action was completed for residents identified as having signs and symptoms of C. difficile when the provider was notified of the change in condition and orders for the change in condition were carried out by the direct care staff.
- The Director of Nursing and the Registered Nurse Managers began in-servicing all licensed nurses, Registered Nurses (RN) and Licensed Practical Nurses (LPN) and certified nursing assistants (CNA) on signs and symptoms of C. difficile.
- RN's and LPN's were additionally educated on notifying the MD for evaluation of C. difficile if a resident has 3 or more loose watery stools in 24 hours, initiating Enteric Contact Isolation when C. difficile is known or suspected, and notifying the MD/NP/PA when interventions are not effective.
- The DON will ensure that all licensed nurses, RN's, LPN's, and CNA's who do not complete the in-service training will not be allowed to work until the training is completed.
- This in-service was incorporated into the new employee facility and agency orientation for all licensed nurses and certified nursing assistants.
Failure to Assess and Treat C. difficile Symptoms
Penalty
Summary
The facility failed to comprehensively assess a resident who was exhibiting signs of Clostridium Difficile (C. difficile) infection, which is a highly contagious bacteria causing diarrhea and inflammation of the colon. The resident, who was admitted with diagnoses including Type 2 diabetes mellitus with chronic kidney disease and muscle weakness, experienced frequent loose and watery stools during her stay. Despite the administration of anti-diarrheal medications, which are contraindicated for C. difficile, the facility did not conduct a thorough assessment to determine the cause of the symptoms or implement effective interventions. Throughout the resident's stay, documentation revealed numerous instances of loose and watery stools, yet the nursing staff failed to perform necessary assessments or notify the Medical Director in a timely manner. The Medical Director was first informed of the diarrhea on a specific date, but no further communication occurred until much later, despite the persistence of symptoms. The facility's Clostridium Difficile policy, which outlines the need for diagnostic testing after three or more watery stools in 24 hours, was not followed, and the resident's symptoms were not adequately communicated to the Medical Director. Interviews with various staff members, including nurses and nursing assistants, indicated a lack of awareness and recall regarding the resident's condition and the actions taken. The Director of Nursing acknowledged that the nursing staff should have assessed the resident for other symptoms of C. difficile and communicated effectively with the Medical Director. The failure to assess and address the resident's symptoms placed her at risk for complications associated with C. difficile, which was confirmed by a positive test after her discharge from the facility.
Deficiency in RN Coverage
Penalty
Summary
The facility failed to schedule a Registered Nurse (RN) for at least 8 consecutive hours on 12 out of 122 days reviewed. This deficiency was identified through a review of the facility's daily schedules for June 2023, July 2023, and from October 1, 2023, through November 30, 2023. During this period, the resident census ranged from 75 to 88. The specific dates without adequate RN coverage were 06/10/23, 06/11/23, 06/24/23, 07/02/23, 07/09/23, 07/23/23, 10/29/23, 11/11/23, 11/12/23, 11/18/23, 11/19/23, and 11/26/23. An interview with the facility's Administrator confirmed awareness of the issue and acknowledged that the facility was not in compliance with the regulatory requirement for RN coverage.
Pharmacist Oversight in Insulin Administration
Penalty
Summary
The Pharmacy Consultant at the facility failed to identify and report a medication administration error involving a resident with type 2 diabetes mellitus. The resident was prescribed Novolog Insulin to be administered with meals, with a specific instruction to hold the insulin if the blood glucose level was less than 120 mg/dl. During the drug regimen reviews conducted in June and July 2024, the Consultant Pharmacist did not recognize that the insulin was administered on ten occasions despite the blood glucose levels being below the specified threshold. This oversight occurred during the monthly drug regimen reviews, where the Pharmacist did not alert the nursing staff about the error. The resident, who was cognitively intact, received insulin doses contrary to the physician's order, which was intended to prevent hypoglycemia. The Physician confirmed the importance of the parameter to hold insulin to avoid low blood sugar levels. The Pharmacist Consultant acknowledged the oversight during a phone interview, admitting that she had overlooked the documentation indicating the insulin was given despite the order to hold it. This failure to follow the prescribed order and the lack of communication about the error contributed to the deficiency identified in the report.
Failure to Follow Insulin Administration Orders
Penalty
Summary
The facility failed to adhere to a physician's order regarding the administration of Novolog Insulin for a resident with type 2 diabetes mellitus. The order specified that the insulin should be held if the resident's blood glucose level was below 120 mg/dl. Despite this, the resident received 10 units of Novolog Insulin on six occasions between June 22, 2024, and July 24, 2024, when their blood glucose levels were below the specified threshold. This was confirmed through a review of the Medication Administration Records and interviews with the nursing staff involved. Nurse #1 admitted to administering the insulin despite the low glucose levels because the resident requested it, citing the resident's rights as justification. Nurse #2, who was also involved, could not recall whether she administered the insulin or signed the record in error. The facility physician confirmed the importance of the order to prevent the resident's blood sugar from dropping too low and expressed an expectation that the nursing staff would follow the order as written.
Infection Control Lapses in Medication Handling and Tube Feeding
Penalty
Summary
The facility failed to maintain proper infection control practices during medication administration and tube feeding care. During a medication administration observation, a medication aide was seen handling various medications with her bare hands, contrary to the facility's policy that prohibits touching pills or tablets with bare hands. The aide was not observed using hand sanitizer or washing her hands before preparing the medications and touched multiple surfaces during the process. Despite having been trained and tested on the correct procedure, the aide admitted to routinely using her bare hands, believing it was acceptable. In another instance, a nurse failed to adhere to enhanced barrier precautions while performing bolus feeding for a resident with a gastrostomy tube. Although a sign outside the resident's door indicated the need for gown and gloves during high-contact activities, the nurse only wore gloves and omitted the gown. The nurse acknowledged forgetting to wear the gown due to nervousness and the newness of the enhanced barrier precautions. Interviews with the Director of Nursing, Assistant Director of Nursing, and the Staff Development Coordinator revealed that staff had been educated multiple times on the enhanced barrier precautions, which had been in effect for several months. Despite this training, the nurse did not follow the required precautions during the procedure, indicating a lapse in adherence to infection control protocols.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Whiteville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Shoreland Health Care And Retirement Center Inc | 0.8 mi | ★★★★★ | 10 | 0 |
| Premier Living And Rehab Center | 10.6 mi | ★★★★★ | 0 | 0 |
| Bladen East Health And Rehab | 19.6 mi | ★★★★★ | 0 | 0 |
| Elizabethtown Healthcare & Rehab Center | 19.8 mi | ★★★★★ | 4 | 0 |
| Brunswick Health & Rehab Center | 22.6 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.