Liberty Commons Nursing and Rehabilitation Center
310 Commerce Drive, Sanford, NC 27332 · Lee County · 80 certified beds · avg 75 residents/day · certified since Dec 7, 2004
Part of chain: LIBERTY SENIOR LIVING (37 facilities, chain avg rating 2.8★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 2/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, repeated · Feb 9, 2023 · F-0686
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Mar 17, 2023 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, repeated · Feb 9, 2023 · F-0835
The facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents.
Why it matters: Poor administration often shows up as understaffing, supply shortages, and care problems across the whole facility.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Mar 17, 2023 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Feb 9, 2023 · F-0580
The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away.
Why it matters: A family could learn about a serious injury or decline days later, after the chance to act has passed.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Mar 17, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Feb 9, 2023 · F-0600
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Mar 17, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Feb 9, 2023 · F-0626
The facility did not let a resident return after a hospital stay or approved leave that lasted longer than the facility's bed-hold policy allowed. Residents generally have the right to come back to the next available bed.
Why it matters: Being refused readmission can leave a hospitalized resident with nowhere to go and separate them from the place they call home.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Mar 17, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Feb 9, 2023 · F-0689
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Aug 18, 2022 (Past Non-Compliance)
All citations in the current public record (34)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| May 5, 2025 | E · Potential for harm, repeated | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| May 5, 2025 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Apr 4, 2024 | E · Potential for harm, repeated | The facility did not provide or arrange dental services for its residents. Nursing homes are responsible for making sure residents can get dental care. |
| Apr 4, 2024 | D · Potential for harm, one-off | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Apr 4, 2024 | D · Potential for harm, one-off | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. |
| Apr 4, 2024 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint |
| Apr 4, 2024 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Apr 4, 2024 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. |
| Apr 4, 2024 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. · from a complaint |
| Apr 4, 2024 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Apr 4, 2024 | D · Potential for harm, one-off | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. |
| Apr 4, 2024 | B · Minimal risk, repeated | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. |
| Feb 9, 2023 | ▲ K · Immediate jeopardy, repeated | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Feb 9, 2023 | ▲ K · Immediate jeopardy, repeated | The facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. |
| Feb 9, 2023 | ▲ J · Immediate jeopardy, one-off | The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. |
| Feb 9, 2023 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. |
| Feb 9, 2023 | ▲ G · Actual harm, one-off | The facility did not let a resident return after a hospital stay or approved leave that lasted longer than the facility's bed-hold policy allowed. Residents generally have the right to come back to the next available bed. |
| Feb 9, 2023 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Feb 9, 2023 | E · Potential for harm, repeated | The facility did not try to gradually reduce doses of mood- and mind-altering medications or use non-drug approaches first, as required, or used 'as needed' psychiatric drugs without proper limits. |
| Feb 9, 2023 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Feb 9, 2023 | E · Potential for harm, repeated | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. |
| Feb 9, 2023 | D · Potential for harm, one-off | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. |
| Feb 9, 2023 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. |
| Feb 9, 2023 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Feb 9, 2023 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| Feb 9, 2023 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Feb 9, 2023 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Feb 9, 2023 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Feb 9, 2023 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Feb 9, 2023 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Feb 9, 2023 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Feb 9, 2023 | D · Potential for harm, one-off | The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems. |
| Feb 9, 2023 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Feb 9, 2023 | C · Minimal risk, facility-wide | The facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (10 → 2).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 22 | 6 | K ▲ |
| 2024 | 10 | 0 | E |
| 2025 | 2 | 0 | E |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | North Carolina avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.21 | 4.01 | 3.95 | bottom 15% in North Carolina; bottom 22% in the U.S. |
| Registered Nurse hours | 0.32 | 0.64 | 0.69 | bottom 11% in North Carolina; bottom 12% in the U.S. |
| Weekend total nurse staffing | 2.97 | 3.56 | 3.50 | bottom 25% in North Carolina; bottom 30% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.27 | 0.41 | 0.48 | bottom 37% in North Carolina; bottom 25% in the U.S. |
| Total nursing staff turnover (%) | 70.5 | 49.0 | 45.8 | bottom 8% in North Carolina; bottom 5% in the U.S. |
| RN turnover (%) | 88.9 | 45.7 | 42.9 | bottom 2% in North Carolina; bottom 2% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.17, RN 0.31, weekend 2.93. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 3/5 · short-stay residents: 3/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| John a McNeill Jr 2012 Irrv Tr | Organization | Indirect Ownership Interest | NOT APPLICABLE | 06/06/2025 |
| Liberty Commons Nursing and Rehabilitation Center of Lee County, LLC | Organization | 5% or Greater Direct Ownership Interest | — | 07/01/2005 |
| Liberty Healthcare Group LLC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 06/06/2025 |
| McNeill, John | Individual | 5% or Greater Direct Ownership Interest | — | 07/01/2005 |
| McNeill, Ronald | Individual | 5% or Greater Direct Ownership Interest | — | 07/01/2005 |
| McNeill, Ronald | Individual | Indirect Ownership Interest | NOT APPLICABLE | 06/06/2025 |
| Ronald B. and Cynthia J. McNeill 2013 Irrevocable Trust | Organization | Indirect Ownership Interest | NOT APPLICABLE | 06/06/2025 |
| Calcutt, Joseph | Individual | Corporate Officer | NOT APPLICABLE | 06/06/2025 |
| Calcutt, Joseph | Individual | ADP of the SNF | NOT APPLICABLE | 06/06/2025 |
| Liberty Healthcare Management INC | Organization | ADP of the SNF | NOT APPLICABLE | 06/06/2025 |
| Long Term Care Management Services LLC | Organization | ADP of the SNF | NOT APPLICABLE | 06/06/2025 |
| McNeill, John | Individual | Corporate Director | NOT APPLICABLE | 08/18/2005 |
| McNeill, Robert | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 01/17/2026 |
| McNeill, Ronald | Individual | Corporate Officer | NOT APPLICABLE | 06/06/2025 |
| Miller, Robert | Individual | Corporate Director | NOT APPLICABLE | 09/01/2024 |
| Miller, Robert | Individual | ADP of the SNF | NOT APPLICABLE | 06/06/2025 |
| Oliver, Anna | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 01/17/2026 |
| Purvis, Jenny | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 01/17/2026 |
| Simpson Tarokh, Leann | Individual | Operational/Managerial Control | NOT APPLICABLE | 06/06/2025 |
| Simpson Tarokh, Leann | Individual | ADP of the SNF | NOT APPLICABLE | 01/17/2026 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "What were the findings behind this administration citation, and what has leadership changed since?"
- "If my family member falls or their condition changes, exactly when and how will I be notified?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "If my family member is hospitalized, what is your bed-hold policy and what guarantees their right to return?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "What systems do you use to prevent medication errors, and what happens when one occurs?"
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Westfield Rehabilitation and Health Center | 3.8 mi | Sanford, NC | ★★★★☆ | 4/5 | |
| Sanford Health & Rehabilitation Co | 10.2 mi | Sanford, NC | ★★★★☆ | 4/5 | |
| Peak Resources - Pinelake | 17.5 mi | Carthage, NC | ★★★★☆ | 4/5 | |
| Emerald Health & Rehab Center | 17.6 mi | Lillington, NC | ★★☆☆☆ | 2/5 |
Compare this facility with the 3 closest →
Facility data as of CMS processing date 2026-08-01. CCN 345532.