Average — CMS composite of the measures below.
A standard survey is most likely before around August 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 & Rehab Center Of Southpor during CMS and state inspections, most recent first.
A resident with terminal cancer, dementia, and a history of falls was found with multiple bruises after an unwitnessed injury. Nursing staff did not promptly perform a comprehensive assessment or timely neurological checks after a nurse aide reported new facial bruising. The assigned nurse failed to investigate or communicate the findings, and neurological assessments were inconsistently documented, with some missing up-to-date vital signs.
A resident with CHF experienced a 27-pound weight gain in one week while on diuretic therapy, but nursing staff did not notify the provider of this significant change. The DON, PA, and MD all confirmed that notification should have occurred for such a weight gain, especially given the resident's CHF diagnosis.
A resident with CHF and on diuretic therapy experienced a documented weekly weight gain of over 27 pounds, but staff did not perform a re-weigh to confirm the accuracy of this measurement. Nursing staff noticed the discrepancy but did not act, and neither the PA nor the MD were informed until later. The DON stated that protocol required re-weighing for changes over 5 pounds, especially for CHF patients, but this was not followed.
The facility did not provide the required 8 hours of RN coverage on one occasion when the scheduled RN called off and a Medication Aide was assigned instead. The DON, who was responsible for finding a replacement, did not secure RN coverage, resulting in no RN being present for that shift.
A resident with heart failure and chronic kidney disease did not receive a physician-ordered Pro BNP lab test because a nurse failed to properly edit and process the order in the electronic medical record, resulting in the test not being performed or documented. The resident, who was receiving hemodialysis and had no acute symptoms, was not aware of the missed lab, and the error was only discovered during a review of records and staff interviews.
A nurse aide failed to perform hand hygiene and did not wear required PPE when entering the room of a resident on contact precautions for multiple MDROs, delivering a meal tray and leaning against the bed before exiting without washing hands. Staff interviews confirmed expectations to follow posted isolation signage, but the aide was confused about the type of precautions required.
A resident with schizophrenia, anxiety, dementia, and constipation did not receive medications on time as prescribed, with delays documented in February and March 2024. The resident expressed a preference for timely administration to avoid being disturbed during sleep. Medication aides cited time management issues and lack of communication with nursing staff as reasons for the delays.
A resident received 59 additional doses of Midodrine due to the facility's failure to clarify a medication order with hold parameters for hypotension. The medication was administered even when the resident's blood pressure was above the specified threshold, as the hold parameter was not included in the MAR after readmission.
A resident with diabetes did not receive 74 units of sliding scale insulin at bedtime over a period of nearly two months due to staff being unaware of the order and miscommunication in the facility. The resident did not experience any significant outcome from this failure.
The facility's QAPI committee failed to maintain procedures and monitor interventions, resulting in repeated deficiencies in medication errors, storage, and unnecessary medications. A resident received 59 additional doses of a medication without proper order clarification, and another did not receive 74 units of insulin as prescribed. The facility also failed to properly label and store medications.
A resident with advanced macular degeneration did not have a timely appointment scheduled with a retinal specialist as recommended. The delay was due to a breakdown in communication and process within the facility, leaving the resident without the necessary evaluation for several months.
The facility failed to record an opened date on two insulin pens and two opened bottles of eye drops, which were found on a medication cart. A nurse admitted to administering one of the undated insulin pens to a resident and was unaware of the labeling requirement.
The facility failed to complete comprehensive assessments within the 14-day required timeframe for two residents. The MDS Nurse cited an increased workload due to a high number of resident discharges and returns as the reason for the delays. The Administrator confirmed the expectation for timely completion of MDS assessments.
Failure to Timely Assess and Monitor Resident After Unwitnessed Injury
Penalty
Summary
A deficiency occurred when nursing staff failed to conduct a comprehensive nursing assessment and timely neurological assessments after a nurse aide reported newly identified facial bruising on a resident following an unwitnessed injury. The resident, who had a history of terminal cancer, dementia, previous falls, and was on anticoagulant therapy, was found with significant bruising to the right side of the face, right shoulder, both knees, left toe, and a reddened area on the left neck. Despite the nurse aide's report of new marks at approximately 5:00 AM, the assigned nurse did not immediately assess the resident or investigate the cause of the injuries. The nurse on duty during the night shift observed red marks on the resident's face during medication administration but did not perform a full assessment or follow up when the nurse aide later reported additional bruising. The nurse assumed the marks had already been addressed by the previous shift and did not communicate any concerns during shift change. The resident was not thoroughly assessed until several hours later by the day shift nurse, who then identified multiple areas of bruising and notified the appropriate clinical leadership and physician. Documentation revealed that neurological assessments were not performed promptly or consistently with up-to-date vital signs following the discovery of the injuries. Some neurological assessments were recorded with outdated vital signs, and there was confusion among staff regarding the facility's protocol for neurological monitoring after unwitnessed injuries. The delay in assessment and incomplete documentation contributed to the deficiency in providing appropriate and timely care for the resident after the injury was identified.
Failure to Notify Provider of Significant Weight Gain in CHF Resident
Penalty
Summary
Staff failed to notify the provider of a significant weight gain in a resident with a history of Congestive Heart Failure (CHF), coronary artery disease, and pulmonary hypertension. The resident was on a diuretic medication and had physician orders for weekly weights. The resident's weight increased by 27.2 pounds in one week, but there was no documentation that the physician or provider was notified of this change. Nursing staff observed the weight gain but did not report it, citing the absence of a specific physician order requiring notification for significant weight changes. Interviews with the Director of Nursing, Physician Assistant, and Medical Director confirmed that their expectation was for the provider to be notified of weight gains greater than 5 pounds, especially for residents with CHF. Both the PA and MD stated they were not made aware of the weight gain and would have expected to be notified to assess and potentially adjust treatment. The deficiency was identified for one resident reviewed for notification of change.
Failure to Verify Significant Weight Gain in Resident with CHF
Penalty
Summary
The facility failed to ensure the accuracy of a weekly weight measurement for a resident with a history of Congestive Heart Failure (CHF) and on diuretic medication. The resident experienced a documented weight gain of 27.2 pounds in one week, but no immediate re-weigh was performed to confirm this significant change. Nursing staff involved in weighing the resident did not initiate a re-weigh, despite noticing the large discrepancy, and there was no documentation of a follow-up weight. The Director of Nursing stated that it was expected for any weight change greater than 5 pounds to be rechecked, especially for residents with CHF, but this protocol was not followed. Interviews with the Physician Assistant and Medical Director revealed that neither was informed of the resident's significant weight gain until after the fact. Both indicated that a re-weigh should have been conducted, and the Medical Director noted that the reported weight gain was likely inaccurate, as the resident did not exhibit related health symptoms and the weight was inconsistent with previous records. The failure to verify the resident's weight compromised the facility's ability to provide care in accordance with professional standards.
Failure to Provide Required RN Coverage for One Shift
Penalty
Summary
The facility failed to provide the required 8 hours of Registered Nurse (RN) coverage on one day during the review period. Payroll Based Journal (PBJ) staffing data indicated that there was no RN coverage on 08/11/24. Review of daily assignment sheets showed that the RN scheduled to work the overnight shift called off, and the replacement was a Medication Aide rather than an RN. During interviews, the Director of Nursing (DON) acknowledged receiving the call-off notification and stated it was her responsibility to find RN coverage, which she did not do. The Administrator confirmed that the on-call staff member is responsible for filling the assignment when there is a call-off, but no RN was present in the building for that shift.
Failure to Obtain Ordered Pro BNP Lab Due to Incomplete Order Processing
Penalty
Summary
A deficiency occurred when the facility failed to obtain a physician-ordered Pro BNP laboratory test for a resident with hypertensive heart disease, Stage 5 chronic kidney disease, and heart failure. The order for the Pro BNP test was entered into the electronic medical record by the physician, but the nurse responsible did not edit the order so that it would trigger on the Medication Administration Record (MAR). As a result, the test was not performed, and there was no documentation of the lab result in the resident's record from the date of the order through the review period. The resident was receiving hemodialysis three times a week and was cognitively intact, with no documented acute symptoms of heart failure during this time. Interviews with facility staff, including the Nurse Practitioner, Physician, and Director of Nursing, confirmed that the lab order was missed due to the failure to properly process the order in the electronic system. The process required the nurse to edit the order, print the resident's face sheet, fill out the lab requisition form, and record the order in the lab book, but these steps were not completed. The error was attributed to the nurse who entered the order, who was no longer employed at the facility. The missed lab was not identified in daily clinical meetings because it did not appear on lab reports due to the incomplete order entry.
Failure to Follow Contact Precaution Protocols for Resident with MDROs
Penalty
Summary
A deficiency occurred when a nurse aide failed to follow the facility's infection prevention and control policies for contact precautions. The aide entered the room of a resident who was on contact precautions for multiple multidrug-resistant organisms (MDROs), including ESBL, E. coli, and MRSA, without performing hand hygiene or donning the required personal protective equipment (PPE) such as gown and gloves. The aide delivered the resident's breakfast tray, leaned against the bed, and exited the room without washing her hands. The aide later stated she was confused about the type of precautions required and did not realize the resident was on contact precautions, mistakenly believing enhanced barrier precautions applied instead. Interviews with facility staff, including a nurse, physician assistant, director of nursing, and the administrator, confirmed that the resident was the only one in the facility on contact precautions and that staff were expected to read and follow the isolation signage posted on the resident's door. The director of nursing acknowledged that staff sometimes did not read the signs and that the facility had not had a contact precaution isolation in some time. The failure to adhere to posted infection control protocols resulted in a breach of the facility's infection prevention and control program.
Failure to Administer Medications on Time
Penalty
Summary
The facility failed to administer medications on time as prescribed by the physician for a resident diagnosed with schizophrenia, anxiety, dementia with behavioral disturbance, and constipation. The resident reported not receiving her medications on time and being woken up after 10:00 PM to receive medications that were due at 8:00 PM. The resident expressed a preference for receiving her medications at the scheduled time to avoid being disturbed during sleep. Despite this, the medications were administered late on multiple occasions in February and March 2024, sometimes as late as 2:00 AM. Review of the Medication Administration Record and Audit Report for February and March 2024 revealed that the medications were consistently administered later than the scheduled time of 8:00 PM. Specific dates and times were documented, showing significant delays in medication administration. Interviews with the medication aides indicated issues with time management and a lack of communication with nursing staff when falling behind schedule. One medication aide admitted to not asking for help to avoid bothering the nurse, while another acknowledged starting the medication pass late and not informing the nurse when behind schedule. The Director of Nursing (DON) confirmed that the medication aides were expected to administer medications within an hour before or after the scheduled time. The DON noted that the medication pass time had been reduced following an audit by a new physician, who discontinued several medications to decrease the workload. Despite these changes, the medication aides were still unable to administer the medications on time, affecting the resident's preference and schedule.
Failure to Clarify Medication Order for Hypotension
Penalty
Summary
The facility failed to clarify a medication order for a resident prescribed Midodrine for hypotension, resulting in the resident receiving 59 additional doses of the medication. The physician's order specified that the medication should be held if the systolic blood pressure was greater than 120 mm/hg, but this hold parameter was not included in the Medication Administration Record (MAR) after the resident's readmission from the hospital. Consequently, the resident received the medication even when their blood pressure readings were above the specified threshold, as documented in the MAR from November 2023 to March 2024. Resident #61, who was admitted with diagnoses including hypertensive chronic kidney disease with end-stage renal disease, dependence on dialysis, and hypotension, was affected by this oversight. Despite the medication being administered incorrectly, there was no significant outcome reported. Interviews with staff revealed that there was confusion and lack of clarity regarding the hold parameters for the medication. Medication aides and the Registered Nurse Supervisor acknowledged that the medication was given in error due to the missing hold parameters in the MAR. The issue was identified during an interview with the physician, who confirmed that the medication should not have been administered when the resident's blood pressure was elevated. The Director of Nursing also acknowledged that the order should have been clarified upon the resident's readmission. The deficiency was attributed to a failure in transcribing and clarifying the medication order, leading to the resident receiving unnecessary doses of Midodrine over several months.
Failure to Administer Bedtime Insulin as Ordered
Penalty
Summary
The facility failed to follow the physician's order to provide sliding scale insulin at bedtime for a resident with diabetes when the blood glucose reading was greater than 200 mg/dl. This resulted in the resident not receiving a total of 74 units of insulin from January 12, 2024, through March 4, 2024. The resident, who was cognitively intact and required limited assistance with activities of daily living, did not experience any significant outcome from this failure. The deficiency was identified through observation, record review, and interviews with staff, a Nurse Practitioner, and a Physician. The Medication Administration Record (MAR) revealed multiple instances where the resident's blood glucose readings were above 200 mg/dl at bedtime, but no insulin was administered. Medication aides and nurses involved in the resident's care were either unaware of the bedtime insulin order or unclear about its administration, leading to the oversight. Interviews with the Nurse Practitioner and Physician indicated that the order for bedtime sliding scale insulin was overlooked for discontinuation, and the electronic medical record did not have a space to document bedtime insulin administration. The Registered Nurse Supervisor and Director of Nursing acknowledged the error, attributing it to a miscommunication and improper entry of the insulin order in the system. Despite daily medication reviews, the issue was not identified until the survey.
Repeated Medication Errors and Storage Issues
Penalty
Summary
The facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor interventions following previous recertification and complaint surveys. This resulted in repeated deficiencies in the areas of significant medication errors, medication storage, and unnecessary medications. Specifically, a resident received 59 additional doses of a medication for hypotension without proper clarification of the medication order, and another resident did not receive a total of 74 units of insulin as prescribed. Additionally, the facility failed to properly label and record opened dates on insulin pens and eye drops, and did not securely store medications on a medication cart. During the recertification and complaint surveys, it was observed that the facility administered a medication that was not medically justified and failed to administer intravenous medication as ordered by the physician. The facility also did not accurately label and record opened dates on various medications, and did not dispose of expired medications. Interviews with the Administrator revealed that the issues were believed to be related to staff inconsistency on specific halls, and two new nurses were hired to address this inconsistency.
Failure to Schedule Retinal Specialist Appointment
Penalty
Summary
The facility failed to obtain an appointment with a retinal specialist for a resident diagnosed with dry eye syndrome and advanced macular degeneration. The resident was admitted with a diagnosis of dry eye syndrome and had a vision consult on 10/17/23, which recommended a referral to a retinal specialist within 2-3 weeks. Despite this, the resident's electronic health record and progress notes showed no evidence of the appointment being scheduled or completed by 3/5/24. The resident expressed difficulty with vision in her left eye and required assistance with reading her mail, indicating the need for the specialist's evaluation was still unmet. Interviews with the Transporter/Appointment Scheduler and the Director of Nursing (DON) revealed a breakdown in communication and process. The Transporter/Appointment Scheduler did not recall receiving the referral, and the DON confirmed that the Medical Records department had not provided the Nurse Practitioner with the optometry report for review. Consequently, the physician was unaware of the need for the referral until 3/7/24. This delay in scheduling the necessary appointment was identified as a system process error by the physician.
Failure to Label Opened Medications
Penalty
Summary
The facility failed to record an opened date on two insulin pens and two opened bottles of eye drops that had shortened expiration dates. This deficiency was observed on one of the three medication carts reviewed for medication storage. Specifically, two Lantus insulin pens, a bottle of Brimonidine eye drops, and a bottle of Latanoprost eye drops were found without opened dates labeled on them during an observation of the 300-hall medication cart. The manufacturer's instructions for these medications require them to be discarded after a specific period post-opening, which was not adhered to in this case. During an interview, Nurse #3 admitted to being unaware that the insulin pens were not dated and acknowledged administering one of the undated insulin pens to a resident earlier that day. She mentioned that she was new to the facility and still getting accustomed to the procedures. The Director of Nursing confirmed that insulin pens and eye drops should be labeled with opened dates when they are opened and that the nurse should have checked the date prior to administering the insulin.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to complete comprehensive assessments within the 14-day required timeframe for two residents. Resident #290 was admitted to the facility and had an admission Minimum Data Set (MDS) noted as in progress beyond the required timeframe. The MDS Nurse acknowledged the delay, attributing it to an increased workload due to a high number of resident discharges and returns. Similarly, Resident #291's admission MDS assessment was completed late. The MDS Nurse admitted to struggling with the workload and being aware of the timelines but had difficulty keeping up. The Administrator confirmed the expectation that MDS assessments be completed in a timely manner.
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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.
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Nursing homes near Southport
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brunswick Rehabilitation And Healthcare Center | 14.6 mi | ★★★★★ | 9 | 0 |
| Autumn Care Of Myrtle Grove | 15.5 mi | ★★★★★ | 7 | 0 |
| Trinity Grove | 16.5 mi | ★★★★★ | 5 | 0 |
| Brunswick Cove Nursing Center | 17.7 mi | ★★★★★ | 15 | 0 |
| Azalea Health & Rehab Center | 18.1 mi | ★★★★★ | 0 | 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.