Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

Liberty Commons Nursing and Rehabilitation Center

Sanford, NC · 80 certified beds · Last Life Safety survey May 5, 2025

CMS Certification Number 345532 · first certified December 2004

Ownership

Operated by LIBERTY SENIOR LIVING · For profit - Limited Liability company

No change of ownership on CMS record since January 1, 2016, when the records begin.

20
Citations on file
Rolling three-year window
4
Life Safety surveys
In the same window
5
Tags cited more than once
Across separate surveys
11
Inspection & testing records
Of the citations on file

Position within NC

20 citations — more than 88% of the 419 certified nursing homes in NC. Compared within NC rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Improvingfewer citations at the latest survey than at its earlier surveys in the window.

The latest survey found 5 citations; the earlier surveys in the window averaged 8. With 4 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

Well past the typical window (June 2026 to August 2026), and past the point by which nine in ten NC facilities have been surveyed. This facility’s last Life Safety survey was May 2025. Facilities in NC are typically surveyed 14–16 months after the last one (median 15), measured over 412 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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Which alerts

3 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

2 of the 20 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

2 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 20 Life Safety citations above. The Physical Environment Index

  • F-0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
  • F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

How that compares

Citations on file over three years

Compared with the median facility in NC, and nationally. Surveyors differ markedly between states, so the NC figure is the meaningful one.

This facility20NC median9National median11
Citations on file over three years, compared
MeasureCitations
This facility20
Median facility in NC9
Median facility nationally11

Survey history

Citations at each Life Safety survey
62023-0292024-0492024-0452025-05
Citations at each Life Safety survey
Survey dateCitations
February 9, 20236
April 4, 20249
April 4, 20249
May 5, 20255

Most-cited tags

Most-cited tags at this facility
K-03213K-07412K-03532K-05112K-03722K-03451K-05211K-09231
Most-cited tags at this facility
TagWhat the surveyor checksTimes citedLast cited
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.32025-05-05
K-0741Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.22025-05-05
K-0353Inspect, test, and maintain automatic sprinkler systems.22024-04-04
K-0511Have properly installed electrical wiring and gas equipment.22025-05-05
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.22024-04-04
K-0345Have approved installation, maintenance and testing program for fire alarm systems.12024-04-04
K-0521Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.12024-04-04
K-0923Have proper medical gas storage and administration areas.12023-02-09

What the citations cover

Citations by CMS category
  • Smoke Deficiencies 10
  • Services Deficiencies 3
  • Emergency Preparedness Deficiencies 2
  • Miscellaneous Deficiencies 2
  • Other 3
Citations by CMS category
CategoryCitations
Smoke Deficiencies10
Services Deficiencies3
Emergency Preparedness Deficiencies2
Miscellaneous Deficiencies2
Gas, Vacuum, and Electrical Systems Deficiencies2
Construction Deficiencies1

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

May 5, 2025 — 5 citations

Citations issued on May 5, 2025
TagWhat the surveyor checksStatus
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.Deficient, Provider has date of correction (August 4, 2025)
K-0352Properly install and monitor supervisory attachments on automatic sprinkler systems.Deficient, Provider has date of correction (August 4, 2025)
K-0363Install corridor and hallway doors that block smoke.Deficient, Provider has date of correction (August 4, 2025)
K-0511Have properly installed electrical wiring and gas equipment.Deficient, Provider has date of correction (August 4, 2025)
K-0741Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.Deficient, Provider has date of correction (August 4, 2025)

April 4, 2024 — 9 citations

Citations issued on April 4, 2024
TagWhat the surveyor checksStatus
E-0037Establish staff and initial training requirements.Deficient, Provider has date of correction (May 3, 2024)
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.Deficient, Provider has date of correction (June 28, 2024)
K-0345Have approved installation, maintenance and testing program for fire alarm systems.Deficient, Provider has date of correction (June 28, 2024)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (June 28, 2024)
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.Deficient, Provider has date of correction (June 28, 2024)
K-0511Have properly installed electrical wiring and gas equipment.Deficient, Provider has date of correction (June 28, 2024)
K-0521Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.Deficient, Provider has date of correction (June 28, 2024)
K-0741Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.Deficient, Provider has date of correction (June 28, 2024)
K-0918Have generator or other power source capable of supplying service within 10 seconds.Deficient, Provider has date of correction (June 28, 2024)

February 9, 2023 — 6 citations

Citations issued on February 9, 2023
TagWhat the surveyor checksStatus
E-0039Conduct testing and exercise requirements.Deficient, Provider has date of correction (March 17, 2023)
K-0161Use approved construction type or materials.Deficient, Provider has date of correction (April 7, 2023)
K-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.Deficient, Provider has date of correction (April 7, 2023)
K-0353Inspect, test, and maintain automatic sprinkler systems.Deficient, Provider has date of correction (April 7, 2023)
K-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.Deficient, Provider has date of correction (April 7, 2023)
K-0923Have proper medical gas storage and administration areas.Deficient, Provider has date of correction (April 7, 2023)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.