Home / North Carolina / Sanford
310 Commerce Drive, Sanford, NC 27332 · Lee County · (919) 499-2206
80 certified beds, about 75 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 2004
CMS Care Compare ratings, data as of September 1, 2026 · CCN 345532 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on May 5, 2025, inspectors cited 2 health deficiencies (the North Carolina average is 4.7, the national average 9.2).
Of 34 health citations since February 2023, 6 were rated as actual harm or immediate jeopardy to residents (3 immediate jeopardy).
CMS lists no fines against this home in the last three years.
Nurses and nurse aides worked 3.17 hours per resident per day, against 3.85 across North Carolina and 3.86 nationally. Registered nurses accounted for 0.31 of those hours.
70.5% of nursing staff left within the year CMS measured (North Carolina average 49.0%).
CMS links it to Liberty Senior Living, an affiliated group of 37 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 34 health citations on file.
Inspectors wroteBased on record review, staff interviews, Pharmacy Consultants, Nurse Practitioner (NP), and Medical Director interviews, the facility failed to discontinue a medication per physician's order resulting in the resident receiving the previous ordered dose of acetaminophen (used to relieve mild to moderate pain) and the newly ordered dose of acetaminophen. This was for 1 of 5 residents (Resident #27) reviewed for unnecessary medications.
Inspectors wroteBased on record reviews, and former Medical Director and staff interviews, the facility failed to prevent a medication error when Nurse #1 administered Ativan ( a medication used to treat anxiety) to Resident #60 that had been prescribed for Resident #57. This deficient practice affected 1 of 5 residents reviewed for unnecessary medications (Resident #60).
Inspectors wroteBased on observations, staff, Nurse Practitioner (NP) #1 interviews and record review, the facility failed to follow dental consult Physician order dated 2/28/24 for 1 (Resident #49) of 1 resident reviewed for dental services.
Inspectors wroteBased on observations, resident, staff interviews and record review, the facility failed to promote dignity by not assisting a resident who required staff assistance with activities of daily living (ADLs) with the removal of facial hair. This was for 1 (Resident #38) 3 residents reviewed for ADLs.
Inspectors wroteBased on observations, staff and responsible party (RP) interviews and record review, the facility failed to honor a resident dependent of staff assistance with his shower preference. This was for 1 of 1 residents (Resident #33) reviewed for choices.
Inspectors wroteBased on observations and interviews with residents and staff, the facility failed to maintain bedside tables free from dried spills and debris for two rooms (room [ROOM NUMBER] and 212), failed to repair a broken dresser drawer (room [ROOM NUMBER]) and failed to ensure a resident ' s bedpan was labeled and stored in a sanitary manner. This deficient practice affected 1 of 3 resident halls (200 Hall).
Inspectors wrote2. Resident #53 was admitted to the facility on [DATE] with diagnoses that included a stroke resulting in hemiplegia (weakness to one side of the body) and hemiparesis (paralysis to one side of the body) of the right dominant side. Resident #53's baseline care plan included a focus area initiated on 2/27/24 for Activities of Daily Living (ADL) self-care performance deficit related to intracranial hemorrhage with right hemiparesis. A review of the Occupational Therapy Evaluation dated 2/27/24 indicated Resident #53's right upper extremity had impaired range of motion. A review of Resident #53's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #53 had moderately impaired cognition and required assistance from staff for ADLs. She was not coded with any range of motion deficits to the upper body. [...]
Inspectors wroteBased on record review and interviews with staff, the facility failed to refer a resident (Residents #25) for a level II Preadmission Screening and Resident Review (PASRR) for a newly diagnosed serious mental illness for 1 of 2 residents reviewed for PASRR.
Inspectors wroteBased on observations, staff interviews and record review, the facility failed to provide nail care to a resident dependent of staff assistance with his activities of daily living (ALDs). This was for 1 (Resident #49) of 4 residents reviewed for ADLs.
Inspectors wroteBased on record reviews and staff interviews, the facility failed to maintain complete and accurate medical records in the areas of dental (Resident #30), urology (Residents #160 and #36) and podiatry (Resident #36). This was for 3 of 21 resident records reviewed.
Inspectors wroteBased on record reviews, observations, responsible party (RP), resident and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor interventions the committee put into place following annual recertification and complaint survey on 2/17/22. This was for seven deficiencies that were cited in the areas of Resident Rights/Exercise of Rights, Self Determination, Notice Requirements Before Transfer/Discharge, Accuracy of Assessments, Care Plan Timing and Revision, Activities of Daily Living Care Provided for Dependent Residents and Resident Records-Identifiable Information. [...]
Inspectors wroteBased on record review and staff interviews, the facility failed to notify the resident and/or the responsible party (RP) in writing of the reason for hospital transfer/discharge for 4 of 4 residents reviewed for hospitalizations (Residents #40, #17, #15 and #2).
Inspectors wroteBased on record review, observation and interviews with Orthopedic Physician Assistant (PA), Wound Nurse, Wound Physician, Medical Director (MD) #2, Director of Nursing (DON) #2, Administrator #2, Nurse Practitioner (NP) #2 and family, the facility failed to prevent the development of a pressure ulcer, protect Resident #16's skin under an immobilizer used following a fractured distal femur (the area of the leg just above the knee joint), perform skin checks under the immobilizer and assess skin. At the first orthopedic follow up appointment, an abrasion was identified. Orders were given to pad an abrasion and consult with a wound physician. The orders were not implemented. Skin checks continued not to be done following the identification of the pressure ulcer. The area deteriorated to an unstageable pressure ulcer. [...]
Inspectors wroteBased on record review and Administrator #1 and Director of Nursing (DON) #1 interviews the facility administration failed to have effective systems in place to prevent, identify, assess, treat, and manage residents with and at risk for pressure sores. This failure resulted in Resident #16 developing an avoidable abrasion under her left leg immobilizer identified on 09/06/22 at an orthopedic consult visit. The abrasion went untreated and area deteriorated into an unstageable pressure ulcer (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) on 9/13/22. The Wound Physician resolved Resident #16's avoidable pressure ulcer on 1/10/23 with an order for 7 days of dressing changes to protect of the healed area. [...]
Inspectors wroteBased on record review and staff, Wound Nurse, Director of Nursing (DON) #2, Medical Director (MD) #2, and Nurse Practitioner (NP) #2 interviews, the facility failed to notify the MD #2 or NP #2 that Resident #16's developed an abrasion to her left lateral calf under her immobilizer on 9/6/22 resulting in no assessment or treatment until 9/13/22 when the area was discovered as an unstageable pressure ulcer (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar). The Wound Physician noted on 9/13/22 the pressure ulcer as measuring 10 centimeters (cm) by 5 cm with 5% of thick adherent black necrotic tissue (eschar) 80% thick adherent devitalized necrotic tissue (slough) and 15% granulation tissue. This was for 1 of 4 residents reviewed for pressure ulcers (Resident #16). [...]
Inspectors wroteBased on staff family, emergency room (ER) Physician, Medical Director #2, Nurse Practitioner (NP) #1 interviews and record review, the facility failed to protect the resident from injury of unknown origin (right proximal tibia/fibula fracture) resulting in physical harm. This was for 1 (Resident #16) of 8 residents reviewed for accidents.
Inspectors wroteBased on record review and Hospital Case Manager, Ombudsman, Business Office Manager, Regional Director, Former Administrator, and current Administrator interviews, the facility failed to permit a resident to return to the facility following a facility-initiated transfer to the hospital for 1 of 1 resident reviewed for hospital transfer. Resident #106 was medically stable to return on [DATE] when the facility refused to readmit the resident. The resident remained in the hospital until [DATE] where she expired. Based on the reasonable person concept a resident transferred to the hospital for an acute condition expects to return to their home at the facility following stabilization at the hospital. [...]
Inspectors wroteBased on observations, staff interviews and record review, the facility failed to prevent a fall on 8/16/22 for a resident with cognitive impairment and poor decision-making skills who required extensive staff assistance with bed mobility and positioning for 1 (Resident #16) of 8 residents reviewed for accidents. Resident #16's rolled from her side onto the floor resulting in a left femur fracture. The bed was in the high position while Nursing Assistant (NA) #11 left the room to throw dirty linens in the laundry bin outside the resident's room.
Inspectors wroteBased on resident, staff, Pharmacy Consultant, Psychiatric Nurse Partitioner (NP), NP #1 and NP #2, Director of Nursing (DON) #1 and Medical Director (MD) #2 interviews, observations and record review, the facility failed to attempt a gradual dose reduction (GDR) of a prescribed antipsychotic last increased on 4/21/21(Resident #29). The facility also failed to ensure orders for as needed (PRN) psychotropic (antianxiety) medications had a stop date (Resident #45 and Resident #12) for 3 of 6 residents whose medications were reviewed for unnecessary medications.
Inspectors wroteBased on observation and staff interview, the facility failed to air dry the insulated plate bases prior to stacking together and ready for use for 44 of 44 insulated plate bases observed. This practice had the potential for cross contamination of food served to residents.
Inspectors wroteBased on record review, observations and interviews with the resident, family, staff, Medical Director, Orthopedic Physician Assistant, Wound Physician, Psychiatric Nurse Practitioner, Nurse Practitioners, Consultant Pharmacist, Wound Nurse and Ombudsman, the facility's Quality Assessment and Assurance (QAA) committee failed to maintain implemented procedures and monitor interventions the committee put into place following the recertification and complaint investigation (CI) survey conducted on 2/17/22. [...]
Inspectors wroteBased on record review, observations, resident and staff interviews, the facility failed to honor a resident's choice related to showers (Resident #10) for 1 of 1 resident reviewed for choices.
Inspectors wroteBased on staff family, emergency room (ER) Physician, Medical Director #2, Nurse Practitioner (NP) #1 interviews and record review, the facility failed to provide evidence of an investigation for an injury of unknown origin (right proximal tibia/fibula fracture) that occurred on 1/18/23. The facility failed to investigate the injury until the surveyor began intervention and investigation on 1/24/23. The facility failed to provide evidence other officials in accordance with State law to include to the State Survey Agency were notified within 2 hours of being made aware of the injury that occurred on 1/18/23 and evidence that an investigation report was submitted within the required 5 working days of the incident. This was for 1 (Resident #16) of 8 residents reviewed for accidents.
Inspectors wroteBased on record review and staff interview, the facility failed to code the Minimum Data Set (MDS) assessments accurately in the areas of bladder incontinence (Resident #45), pressure ulcer (Resident #46) & nutrition (Resident #12) for 3 of 20 sampled residents whose MDS were reviewed.
Inspectors wroteBased on observations, record review and staff interviews, the facility failed to develop and implement a comprehensive care plan with measurable objectives and interventions in the areas of oxygen therapy and pressure ulcers for 2 of 2 sampled resident (Resident #3 and Resident #16) reviewed for comprehensive care plans.
Inspectors wroteBased on record review and staff interview, the facility failed to review and revise the care plan in the areas of code status (Resident #45) and pressure ulcer (Resident #12) for 2 of 20 sampled residents whose care plans were reviewed.
Inspectors wroteBased on observations, record reviews, resident and staff interviews, the facility failed to trim and clean dependent residents' nails (Residents #10 and #12) and failed to provide incontinent care (Resident # 46) for 3 of 8 residents reviewed for Activities of Daily Living (ADL's).
Inspectors wroteBased on record review, observations, staff and Wound Physician interviews, the facility failed to provide wound care as ordered by the Wound Physician to a diabetic ulcer on the lower extremity (Resident #10) for 1 of 3 residents reviewed for well-being.
Inspectors wroteBased on record review, observations, resident, staff and Nurse Practitioner interviews, the facility failed to schedule an Orthopedic appointment as ordered (Resident #28) for 1 of 1 resident reviewed for limited range of motion.
Inspectors wroteBased on record review, observation and resident and staff interview, the facility failed to secure a urinary catheter to prevent tension or accidental removal for 1 of 2 sampled residents reviewed with indwelling urinary catheters (Resident #45).
Inspectors wroteBased on record review, observations and staff interviews, the facility failed to ensure oxygen therapy was provided as ordered by the physician for 1 of 1 sampled residents of oxygen therapy (Resident #3). Additionally, the facility failed to display cautionary signage indicating oxygen in use for 2 of 2 residents observed (Resident #3 and #10).
Inspectors wroteBased on record review, Consultant Pharmacist, Nurse Practitioner, and staff interviews, the facility failed to act upon recommendations made by the Consultant Pharmacist for 1 of 6 residents whose medications were reviewed (Resident #12).
Inspectors wroteBased on record review and staff interviews, the facility failed to maintain accurate medical records for 1 of 1 resident reviewed for diabetic wound care (Resident #10).
Inspectors wroteBased on record review and interview with the Ombudsman, residents and staff, the facility failed to notify the resident and or responsible party (RP) in writing of the reason for the transfer/discharge to the hospital and failed to send a copy of the discharge notice to the Ombudsman for 3 of 3 sampled residents reviewed for hospitalization (Residents #44, #5 & #50).
20 fire safety citations on file: 5 on May 5, 2025, 9 on April 4, 2024, 6 on February 9, 2023.
CMS lists no fines or payment denials against this home in the last three years. The national average is 0.9 fines per home.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | North Carolina | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.17 | 3.85 | 3.86 |
| Registered nurses | 0.31 | 0.62 | 0.69 |
| All nursing staff on weekends | 2.93 | 3.42 | 3.42 |
| Nurse aides | 1.82 | ||
| Licensed practical nurses | 1.03 | ||
| Nursing staff turnover (share who left in a year) | 70.5% | 49.0% | 45.8% |
| Registered nurse turnover | 88.9% | 45.6% | 42.9% |
| Administrators who left | 0 |
CMS expects 3.78 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.26 on weekdays and 2.93 on weekends, 10% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 14.2% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.40 in April to June 2025 to 3.17 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.17 | 0.31 | 3.26 | 2.93 | 14.2% | 0 of 90 | 75 |
| Oct to Dec 2025 | 3.15 | 0.37 | 3.27 | 2.84 | 22.6% | 0 of 92 | 74 |
| Jul to Sep 2025 | 3.18 | 0.32 | 3.27 | 2.96 | 35.9% | 0 of 92 | 77 |
| Apr to Jun 2025 | 3.40 | 0.32 | 3.54 | 3.06 | 32.7% | 0 of 91 | 76 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| North Carolina, Jan to Mar 2026 | 3.65 | 0.53 | 3.82 | 3.25 | 8.0% | 0.7% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| North Carolina, all employers | |||
| CNAs (nursing assistants) | $18.49 | $17.28 to $21.08 | 64,010 |
| LPNs and LVNs | $30.42 | $28.50 to $33.51 | 18,010 |
| Registered nurses | $40.56 | $37.87 to $49.06 | 111,120 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | North Carolina | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 7.8 | 15.6 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 3.6 | 0.7 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 2.9 | 2.3 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 5.0 | 3.5 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.0 | 1.4 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 9.6 | 18.3 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 7.5 | 5.5 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 11.8 | 14.0 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 34.4 | 22.9 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 11.8 | 12.9 | 12.0 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Liberty Commons Nursing and Rehabilitation Center's Medicare short-stay residents. On returning residents home or to the community, CMS rates it no different from the national rate (57.6% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
57.6% this home
No different from the national rate
US median of homes 51.5% · North Carolina: 93 better, 25 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 35 eligible stays.
10.4% this home
No different from the national rate
US median of homes 10.7% · North Carolina: 1 better, 4 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 41 eligible stays.
6.5% this home
No different from the national rate
US median of homes 7.1% · North Carolina: 1 better, 3 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 29 eligible stays.
36.4% this home
Median of homes: North Carolina54.0% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 22 residents counted.
6.1% this home
Median of homes: North Carolina0.6% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 33 residents counted.
3.1% this home
Median of homes: North Carolina2.5% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 33 residents counted.
Not reported
CMS note: The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure.
Median of homes: North Carolina97.5% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 18 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: LIBERTY HEALTHCARE GROUP LLC. CMS links this home to Liberty Senior Living, a group of 37 nursing homes averaging 2.8 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Liberty Commons Nursing and Rehabilitation Center of Lee County, LLC | 5% or greater direct ownership interest | Organization | 07/01/2005 | |
| McNeill, John | 5% or greater direct ownership interest | Individual | 07/01/2005 | |
| McNeill, Ronald | 5% or greater direct ownership interest | Individual | 07/01/2005 | |
| John a McNeill Jr 2012 Irrv Tr | Indirect ownership interest | Organization | 06/06/2025 | |
| Liberty Healthcare Group LLC | Indirect ownership interest | Organization | 06/06/2025 | |
| Ronald B. and Cynthia J. McNeill 2013 Irrevocable Trust | Indirect ownership interest | Organization | 06/06/2025 | |
| McNeill, Ronald | Indirect ownership interest | Individual | 06/06/2025 | |
| McNeill, John | Corporate director | Individual | 08/18/2005 | |
| Miller, Robert | Corporate director | Individual | 09/01/2024 | |
| Wilson, Jeffrey | Corporate director | Individual | 07/01/2005 | |
| Calcutt, Joseph | Corporate officer | Individual | 06/06/2025 | |
| McNeill, Ronald | Corporate officer | Individual | 06/06/2025 | |
| Wilson, Jeffrey | Corporate officer | Individual | 06/06/2025 | |
| Simpson Tarokh, Leann | Operational/managerial control | Individual | 06/06/2025 | |
| Watson, William | Operational/managerial control | Individual | 06/06/2025 | |
| McNeill, Robert | Individual is an owner, partner or trustee of any ADP of the SNF | Individual | 01/17/2026 | |
| Oliver, Anna | Individual is an owner, partner or trustee of any ADP of the SNF | Individual | 01/17/2026 | |
| Purvis, Jenny | Individual is an owner, partner or trustee of any ADP of the SNF | Individual | 01/17/2026 | |
| Wilson, Jeffrey | Individual is an owner, partner or trustee of any ADP of the SNF | Individual | 01/17/2026 | |
| Liberty Healthcare Management Inc | Adp of the SNF | Organization | 06/06/2025 | |
| Long Term Care Management Services LLC | Adp of the SNF | Organization | 06/06/2025 | |
| Calcutt, Joseph | Adp of the SNF | Individual | 06/06/2025 | |
| Miller, Robert | Adp of the SNF | Individual | 06/06/2025 | |
| Simpson Tarokh, Leann | Adp of the SNF | Individual | 01/17/2026 | |
| Wilson, Jeffrey | Adp of the SNF | Individual | 06/06/2025 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
These are the official offices in North Carolina. NursingHomeClear cannot take or act on complaints.