Liberty Commons Nursing and Rehabilitation Center

Also known publicly as Liberty Commons Nursing & Rehabilitation Center of Lee County

Sanford, NC

CMS provider ID 345532CMS source updated July 29, 2026

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CMS overview

CMS rating overview

CMS overall

3 of 5 CMS stars

Health inspection

4 of 5 CMS stars

Staffing

1 of 5 CMS stars

Quality-measure

3 of 5 CMS stars

No proprietary TrustHub score. These ratings are published separately by CMS.

How CMS describes these ratings
CMS overall rating
The CMS overall rating summarizes health inspections, staffing, and quality measures within Medicare's Five-Star system.
Health inspection rating
The CMS health inspection rating reflects findings from standard and complaint inspections used in Medicare's Five-Star system.
Staffing rating
The CMS staffing rating reflects staffing levels and related measures used in Medicare's Five-Star system.
Quality-measure rating
The CMS quality-measure rating summarizes selected resident assessment and claims-based measures used in Medicare's Five-Star system.
CMS certified beds
80
Ownership descriptor
For profit - Limited Liability company
Medicare participation
Yes
Medicaid participation
Yes

Facility information

Contact

CMS remains the primary federal record. Public website and additional contact details appear only when independently verified.

Phone
9194992206Verified public information · checked Aug 2026
Also known publicly as
Liberty Commons Nursing & Rehabilitation Center of Lee CountyVerified public information · checked Aug 2026

Decision guide

What to review

Factual evidence to examine before you decide. These summaries are not a score or recommendation.

Staffing

CMS publishes a 1-star staffing rating for this facility.

RN staffing was 0.31 hours per resident day in 2026Q1, calculated from CMS PBJ records.

View staffing evidence

Chain context

CMS groups this facility with a chain covering 37 facilities across 2 states or territories.

View chain evidence

Ownership & operation

Ownership & Operation

Operator, licensee, owner, manager, and chain stay separate. A connected organization is not automatically the party that runs daily operations.

Ownership type
For profit - Limited Liability companyCMS
Chain
LIBERTY SENIOR LIVINGCMS identifies this facility as part of the LIBERTY SENIOR LIVING chain.
Related facilities
35Current CMS organization identity

Explore ownership network →

Who is behind this facility?

SeniorTrustHub found evidence connecting this facility to:

  • 4 CMS-reported ownership organizations
  • CMS reports 19 individual ownership interests
  • a CMS chain / common-control group

Related facilities

35 currently connected nursing homes share this CMS organization identity with LIBERTY HEALTHCARE GROUP LLC.

Average CMS overall rating
2.8 stars across 35 reporting facilities
CMS monetary penalties
20 of 35 facilities had a recorded monetary penalty in the available CMS period.
Recent CMS penalties
7 facilities had a CMS penalty in the last 18 months.
Recent high-value CMS enforcement
5 facilities had a high-value CMS fine or payment denial in the last 18 months.
Recent CMS complaint inspections
17 facilities had a CMS complaint inspection in the last 18 months.
Total recorded CMS fines
$902,277

These figures summarize currently connected CMS-certified nursing homes. Some facilities have incomplete measures; missing values are omitted, not treated as zero. Ownership structures can change. State operator or licensee evidence may differ from CMS ownership disclosures.

Ownership

Who CMS records show is connected to this facility

These are CMS-published ownership disclosures. Medicare enrollment ownership and managerial-control information is reported by enrolled providers through CMS forms; it is not an independent determination of beneficial ownership.

Reported party records
26
Organizations shown
7
Individuals shown
19
Latest ownership source update
Jul 27, 2026

CMS-published ownership and control parties

  • LIBERTY COMMONS NURSING AND REHABILITATION CENTER OF LEE COUNTY, LLC

    Organization · 5% OR GREATER DIRECT OWNERSHIP INTEREST

    Association date reported to CMS: Jul 1, 2005

    Other facilities connected through this exact CMS organization identity: 0 across NC.

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • MCNEILL, JOHN

    Individual · 5% OR GREATER DIRECT OWNERSHIP INTEREST

    Association date reported to CMS: Jul 1, 2005

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • MCNEILL, RONALD

    Individual · 5% OR GREATER DIRECT OWNERSHIP INTEREST

    Association date reported to CMS: Jul 1, 2005

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • CALCUTT, JOSEPH

    Individual · ADP OF THE SNF

    Association date reported to CMS: Jun 6, 2025

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • LIBERTY HEALTHCARE MANAGEMENT INC

    Organization · ADP OF THE SNF

    Association date reported to CMS: Jun 6, 2025

    Other facilities connected through this exact CMS organization identity: 0 across NC.

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • LONG TERM CARE MANAGEMENT SERVICES LLC

    Organization · ADP OF THE SNF

    Association date reported to CMS: Jun 6, 2025

    Other facilities connected through this exact CMS organization identity: 0 across NC.

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • MILLER, ROBERT

    Individual · ADP OF THE SNF

    Association date reported to CMS: Jun 6, 2025

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • SIMPSON TAROKH, LEANN

    Individual · ADP OF THE SNF

    Association date reported to CMS: Jan 17, 2026

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • WILSON, JEFFREY

    Individual · ADP OF THE SNF

    Association date reported to CMS: Jun 6, 2025

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • MCNEILL, JOHN

    Individual · CORPORATE DIRECTOR

    Association date reported to CMS: Aug 18, 2005

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • MILLER, ROBERT

    Individual · CORPORATE DIRECTOR

    Association date reported to CMS: Sep 1, 2024

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • WILSON, JEFFREY

    Individual · CORPORATE DIRECTOR

    Association date reported to CMS: Jul 1, 2005

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • CALCUTT, JOSEPH

    Individual · CORPORATE OFFICER

    Association date reported to CMS: Jun 6, 2025

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • MCNEILL, RONALD

    Individual · CORPORATE OFFICER

    Association date reported to CMS: Jun 6, 2025

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • WILSON, JEFFREY

    Individual · CORPORATE OFFICER

    Association date reported to CMS: Jun 6, 2025

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • JOHN A MCNEILL JR 2012 IRRV TR

    Organization · INDIRECT OWNERSHIP INTEREST

    Association date reported to CMS: Jun 6, 2025

    Other facilities connected through this exact CMS organization identity: 0 across NC.

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • LIBERTY HEALTHCARE GROUP LLC

    Organization · INDIRECT OWNERSHIP INTEREST

    Association date reported to CMS: Jun 6, 2025

    Other facilities connected through this exact CMS organization identity: 0 across NC.

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • MCNEILL, RONALD

    Individual · INDIRECT OWNERSHIP INTEREST

    Association date reported to CMS: Jun 6, 2025

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • RONALD B. AND CYNTHIA J. MCNEILL 2013 IRREVOCABLE TRUST

    Organization · INDIRECT OWNERSHIP INTEREST

    Association date reported to CMS: Jun 6, 2025

    Other facilities connected through this exact CMS organization identity: 0 across NC.

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • MCNEILL, ROBERT

    Individual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF

    Association date reported to CMS: Jan 17, 2026

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • OLIVER, ANNA

    Individual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF

    Association date reported to CMS: Jan 17, 2026

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • PURVIS, JENNY

    Individual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF

    Association date reported to CMS: Jan 17, 2026

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • WILSON, JEFFREY

    Individual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNF

    Association date reported to CMS: Jan 17, 2026

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • SIMPSON TAROKH, LEANN

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Jun 6, 2025

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • WATSON, WILLIAM

    Individual · OPERATIONAL/MANAGERIAL CONTROL

    Association date reported to CMS: Jun 6, 2025

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Ownership
    CMS dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source
  • LIBERTY HEALTHCARE GROUP LLC

    Organization · Medicare-enrolled legal organization

    Other facilities connected through this exact CMS organization identity: 34 across NC, TN.

    View ownership source details
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset
    Skilled Nursing Facility Enrollments
    CMS dataset identifier
    5f2c306f-3b1c-42cd-b037-187b2ce22126
    Source updated
    Jul 27, 2026
    Retrieved
    Aug 15, 2026
    View official CMS source

What this means

Roles are shown as CMS publishes them. Different CMS sources can describe different enrollment, ownership, and control concepts, so TrustHub keeps each source-specific disclosure distinct.

Questions to ask

  • CMS records list several organizations with ownership or control roles. Which entity is responsible for day-to-day operations at this facility?
  • CMS records connect LIBERTY HEALTHCARE GROUP LLC to 35 facilities. Which policies and staffing decisions are managed centrally versus locally?

Chain context

CMS groups this facility with LIBERTY SENIOR LIVING

Chain-level values describe this CMS-defined group, not any one facility. CMS Chain ID 310 is a grouping identifier, not a legal organization.

Facilities
37
States and territories
2
Average overall rating
2.8
Average staffing rating
2.2
Average total nurse HPRD
3.6
Total fines
38
Review CMS chain evidence

CMS-published history

Monthly chain measures
MonthFacilitiesOverall ratingStaffing rating
Wed Jul372.82.2
Mon Jun372.72.1
Fri May372.62.1
Wed Apr372.62.1
Sun Mar352.62.1
Sun Feb342.62.1

Questions to ask

  • CMS groups facilities in 2 states or territories under this chain. Which operational policies are set at the chain level?
  • CMS reports 38 fines across the chain in this dataset. What compliance functions are managed centrally?
CMS chain source and methodology

Nursing Home Chain Performance Measures, fixed version da2db00a-0f3d-40a9-a535-588ff1220c55. Membership comes separately from CMS Skilled Nursing Facility Enrollments.

View official CMS source

Inspections & deficiencies

What CMS inspection records show

Scope and severity terms below are CMS classifications. They are not a TrustHub score.

Latest recorded inspection

Date
May 5, 2025
Survey type
Fire Safety Standard
Linked findings
0
Highest linked CMS classification
No linked health-deficiency finding in the loaded record
View source details
Dataset
Inspection Dates
CMS dataset ID
svdt-c123
CMS source updated
Jul 1, 2026
CMS provider ID
345532
Source record locator
csv-row:90087:ccn:345532
View official CMS source
May 5, 2025Fire Safety Standard 0 linked findings

No health-deficiency rows were deterministically linked to this inspection.

May 5, 2025Health Standard 2 linked findings
  • F0658Resident Assessment and Care Planning Deficiencies

    Ensure services provided by the nursing facility meet professional standards of quality.

    CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (May 22, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    345532
    Source record locator
    csv-row:250812:ccn:345532
    View official CMS source
  • F0760Pharmacy Service Deficiencies

    Ensure that residents are free from significant medication errors.

    CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (May 22, 2025)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    345532
    Source record locator
    csv-row:250811:ccn:345532
    View official CMS source
Apr 4, 2024Fire Safety Complaint 0 linked findings

No health-deficiency rows were deterministically linked to this inspection.

Apr 4, 2024Fire Safety Standard 0 linked findings

No health-deficiency rows were deterministically linked to this inspection.

Apr 4, 2024Health Complaint 0 linked findings

No health-deficiency rows were deterministically linked to this inspection.

Apr 4, 2024Health Standard 7 linked findings
  • F0561Resident Rights Deficiencies

    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

    CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (May 3, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    345532
    Source record locator
    csv-row:250815:ccn:345532
    View official CMS source
  • F0623Resident Rights Deficiencies

    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

    CMS scope/severity B: Pattern; No actual harm with potential for minimal harm.

    Correction status: Deficient, Provider has plan of correction (May 3, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    345532
    Source record locator
    csv-row:250822:ccn:345532
    View official CMS source
  • F0641Resident Assessment and Care Planning Deficiencies

    Ensure each resident receives an accurate assessment.

    CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (May 3, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    345532
    Source record locator
    csv-row:250817:ccn:345532
    View official CMS source
  • F0644Resident Assessment and Care Planning Deficiencies

    Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

    CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (May 3, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    345532
    Source record locator
    csv-row:250818:ccn:345532
    View official CMS source
  • F0791Quality of Life and Care Deficiencies

    Provide or obtain dental services for each resident.

    CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (May 3, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    345532
    Source record locator
    csv-row:250813:ccn:345532
    View official CMS source
  • F0842Resident Assessment and Care Planning Deficiencies

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

    CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (May 3, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    345532
    Source record locator
    csv-row:250820:ccn:345532
    View official CMS source
  • F0867Administration Deficiencies

    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

    CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (May 3, 2024)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    345532
    Source record locator
    csv-row:250821:ccn:345532
    View official CMS source
Jul 6, 2023Health Complaint 2 linked findings
  • F0689Quality of Life and Care Deficiencies

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Aug 15, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    345532
    Source record locator
    csv-row:250823:ccn:345532
    View official CMS source
  • F0867Administration Deficiencies

    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

    CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Aug 15, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    345532
    Source record locator
    csv-row:250824:ccn:345532
    View official CMS source
Feb 9, 2023Fire Safety Standard 0 linked findings

No health-deficiency rows were deterministically linked to this inspection.

Feb 9, 2023Health Standard 22 linked findings
  • F0561Resident Rights Deficiencies

    Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

    CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Mar 17, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    345532
    Source record locator
    csv-row:250834:ccn:345532
    View official CMS source
  • F0580Resident Rights Deficiencies

    Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

    CMS scope/severity J: Isolated; Immediate jeopardy to resident health or safety.

    Correction status: Deficient, Provider has date of correction (Mar 17, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    345532
    Source record locator
    csv-row:250827:ccn:345532
    View official CMS source
  • F0600Freedom from Abuse, Neglect, and Exploitation Deficiencies

    Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

    CMS scope/severity G: Isolated; Actual harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Mar 17, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    345532
    Source record locator
    csv-row:250828:ccn:345532
    View official CMS source
  • F0610Freedom from Abuse, Neglect, and Exploitation Deficiencies

    Respond appropriately to all alleged violations.

    CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Mar 17, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    345532
    Source record locator
    csv-row:250835:ccn:345532
    View official CMS source
  • F0623Resident Rights Deficiencies

    Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

    CMS scope/severity C: Widespread; No actual harm with potential for minimal harm.

    Correction status: Deficient, Provider has plan of correction (Mar 17, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    345532
    Source record locator
    csv-row:250846:ccn:345532
    View official CMS source
  • F0626Resident Rights Deficiencies

    Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.

    CMS scope/severity G: Isolated; Actual harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Mar 17, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    345532
    Source record locator
    csv-row:250829:ccn:345532
    View official CMS source
  • F0641Resident Assessment and Care Planning Deficiencies

    Ensure each resident receives an accurate assessment.

    CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Mar 17, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    345532
    Source record locator
    csv-row:250836:ccn:345532
    View official CMS source
  • F0656Resident Assessment and Care Planning Deficiencies

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

    CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Mar 17, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    345532
    Source record locator
    csv-row:250837:ccn:345532
    View official CMS source
  • F0657Resident Assessment and Care Planning Deficiencies

    Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

    CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Mar 17, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    345532
    Source record locator
    csv-row:250838:ccn:345532
    View official CMS source
  • F0677Quality of Life and Care Deficiencies

    Provide care and assistance to perform activities of daily living for any resident who is unable.

    CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Mar 17, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    345532
    Source record locator
    csv-row:250839:ccn:345532
    View official CMS source
  • F0684Quality of Life and Care Deficiencies

    Provide appropriate treatment and care according to orders, resident’s preferences and goals.

    CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Mar 17, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    345532
    Source record locator
    csv-row:250840:ccn:345532
    View official CMS source
  • F0686Quality of Life and Care Deficiencies

    Provide appropriate pressure ulcer care and prevent new ulcers from developing.

    CMS scope/severity K: Pattern; Immediate jeopardy to resident health or safety.

    Correction status: Deficient, Provider has date of correction (Mar 17, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    345532
    Source record locator
    csv-row:250825:ccn:345532
    View official CMS source
  • F0688Quality of Life and Care Deficiencies

    Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

    CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Mar 17, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    345532
    Source record locator
    csv-row:250841:ccn:345532
    View official CMS source
  • F0689Quality of Life and Care Deficiencies

    Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

    CMS scope/severity G: Isolated; Actual harm that is not immediate jeopardy.

    Correction status: Past Non-Compliance (Aug 18, 2022)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    345532
    Source record locator
    csv-row:250830:ccn:345532
    View official CMS source
  • F0690Quality of Life and Care Deficiencies

    Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

    CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Mar 17, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    345532
    Source record locator
    csv-row:250842:ccn:345532
    View official CMS source
  • F0695Quality of Life and Care Deficiencies

    Provide safe and appropriate respiratory care for a resident when needed.

    CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Mar 17, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    345532
    Source record locator
    csv-row:250843:ccn:345532
    View official CMS source
  • F0756Pharmacy Service Deficiencies

    Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

    CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Mar 17, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    345532
    Source record locator
    csv-row:250844:ccn:345532
    View official CMS source
  • F0758Pharmacy Service Deficiencies

    Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

    CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Mar 17, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    345532
    Source record locator
    csv-row:250831:ccn:345532
    View official CMS source
  • F0812Nutrition and Dietary Deficiencies

    Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

    CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Mar 17, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    345532
    Source record locator
    csv-row:250832:ccn:345532
    View official CMS source
  • F0835Administration Deficiencies

    Administer the facility in a manner that enables it to use its resources effectively and efficiently.

    CMS scope/severity K: Pattern; Immediate jeopardy to resident health or safety.

    Correction status: Deficient, Provider has date of correction (Mar 17, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    345532
    Source record locator
    csv-row:250826:ccn:345532
    View official CMS source
  • F0842Resident Assessment and Care Planning Deficiencies

    Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

    CMS scope/severity D: Isolated; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Mar 17, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    345532
    Source record locator
    csv-row:250845:ccn:345532
    View official CMS source
  • F0867Administration Deficiencies

    Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

    CMS scope/severity E: Pattern; No actual harm with potential for more than minimal harm that is not immediate jeopardy.

    Correction status: Deficient, Provider has date of correction (Mar 17, 2023)

    View source details
    Dataset
    Health Deficiencies
    CMS dataset ID
    r5ix-sfxw
    CMS source updated
    Jul 1, 2026
    CMS provider ID
    345532
    Source record locator
    csv-row:250833:ccn:345532
    View official CMS source

Tags appearing across inspections

  • F0867 appears in 3 linked inspections.
  • F0561 appears in 2 linked inspections.
  • F0623 appears in 2 linked inspections.
  • F0641 appears in 2 linked inspections.
  • F0689 appears in 2 linked inspections.
  • F0842 appears in 2 linked inspections.

Penalties & enforcement

CMS penalty records in the loaded three-year dataset

No penalty records were found for this provider in the currently loaded CMS Penalties dataset.

Questions to ask

Questions generated from the evidence above

  • CMS records show F0867 in 3 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0561 in 2 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0623 in 2 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0641 in 2 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0689 in 2 inspections in the available record. What changes has the facility made to address this issue?
  • CMS records show F0842 in 2 inspections in the available record. What changes has the facility made to address this issue?

Facility history

Facility History

7 historical events available. Dates and values come from published CMS and official state regulator evidence, not a score.

What changed recently?

  • Total nurse staffing decreasedTotal nurse staffing decreased from 3.40 to 3.18 hours per resident day between 2025Q2 and 2025Q3. Staffing declined across those reported periods.
  • Health inspection completed2 deficiencies were recorded.

2025

  1. Total nurse staffing decreased

    Total nurse staffing decreased from 3.40 to 3.18 hours per resident day between 2025Q2 and 2025Q3. Staffing declined across those reported periods.

    3.403.18

    CMS · Reported in a source release · View related evidence

  2. Health inspection completed

    2 deficiencies were recorded.

    CMS · Recorded event date · View related evidence

2024

  1. Health inspection completed

    7 deficiencies were recorded.

    CMS · Recorded event date · View related evidence

  2. Complaint inspection recorded

    No linked health-deficiency findings were recorded for this survey.

    CMS · Recorded event date · View related evidence

  3. Fire-safety complaint inspection recorded

    No linked health-deficiency findings were recorded for this survey.

    CMS · Recorded event date · View related evidence

2023

  1. Complaint inspection recorded

    2 deficiencies were recorded.

    CMS · Recorded event date · View related evidence

  2. Health inspection completed

    22 deficiencies were recorded. That includes 6 higher-severity deficiencies.

    CMS · Recorded event date · View related evidence

Staffing

Reported nursing staffing at a glance

CMS staffing rating: 1 of 5 stars. CMS calculates that rating separately using its published methodology. The values below are calculations from daily PBJ records for 2026Q1 (current source quarter).

Inspect a PBJ quarter
Total nursing
3.166
reported hours per resident day
RN categories
0.315
reported hours per resident day
LPN/LVN categories
1.03
reported hours per resident day
CNA
1.812
reported hours per resident day

Weekday and weekend calculations

2026Q1 reported hours per resident day
MeasureMonday–FridaySaturday–Sunday
Total nursing3.2592.934
RN categories0.3340.268

Contract staff accounted for 14.2% of reported nursing hours included in this quarter calculation.

Reported RN-category hours per resident day were 0.057 lower than the prior loaded quarter.

Staffing over time

Solid bar: Total nursing · Outlined bar: RN categories

Calculated reported hours per resident day by PBJ quarter
QuarterTotal nursingRN categoriesLPN/LVNCNAContract shareDays
2025Q23.4030.321.1041.9832.7%91
2025Q33.1830.3191.0441.8235.9%92
2025Q43.1490.3720.9361.84122.6%92
2026Q13.1660.3151.031.81214.2%90

Questions to ask

  • PBJ records show lower calculated RN-category hours per resident day on weekends this quarter. How does the facility plan RN coverage on Saturdays and Sundays?
  • PBJ records show that some reported nursing hours were contract hours. How does the facility orient and integrate contract staff?
Staffing source and calculation details
Source
Centers for Medicare & Medicaid Services (CMS)
Dataset
Payroll Based Journal Daily Nurse Staffing
CMS dataset ID
7e0d53ba-8f02-4c66-98a5-14a1c997c50d
Quarter
2026Q1
Coverage
Jan 1, 2026Mar 31, 2026
Days represented
90 (90 with positive MDS census)
CMS source updated
Jul 29, 2026
Calculation version
pbj-quarter-ratio-of-sums-v1

Hours-per-resident-day values are calculated by this platform from CMS-published daily PBJ hours and MDS census. For each displayed period, included hours are summed and divided by the summed census for days with a positive census. They are not CMS case-mix-adjusted staffing measures or a staffing rating.

View official CMS PBJ source

What we can verify today

Current Provider Information facts

These measures come from the current successfully ingested CMS Nursing Home Provider Information release.

  • CMS reports a 3-star overall rating.
  • CMS reports a 4-star health inspection rating.
  • CMS reports a 1-star staffing rating.
  • CMS reports a 3-star quality-measure rating.

Planned evidence layers

Additional public-source research

These areas require separate authoritative CMS datasets. No findings are shown until those sources are ingested and reviewed.

    Trust participation

    See something that needs correction?

    Claims, corrections, and factual context are free. Submissions never replace CMS evidence or affect ranking.

    How corrections work

    Source register

    See where this record came from

    Provider Information
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset identifier
    4pq5-n9py
    Source updated
    Jul 29, 2026
    Retrieved
    Aug 14, 2026
    Supports
    Overview, facility facts, and CMS ratings
    View official CMS source
    Inspection Dates
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset identifier
    svdt-c123
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 14, 2026
    Supports
    Inspections and facility history
    View official CMS source
    Health Deficiencies
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset identifier
    r5ix-sfxw
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 14, 2026
    Supports
    Health deficiencies and facility history
    View official CMS source
    Payroll Based Journal Daily Nurse Staffing
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset identifier
    7e0d53ba-8f02-4c66-98a5-14a1c997c50d
    Coverage
    Apr 1, 2025–Mar 31, 2026
    Source updated
    Jul 29, 2026
    Retrieved
    Aug 15, 2026
    Supports
    PBJ staffing cards, history, and transparent calculations
    View official CMS source
    Ownership
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset identifier
    y2hd-n93e
    Source updated
    Jul 1, 2026
    Retrieved
    Aug 15, 2026
    Supports
    Ownership parties, organization connections, and ownership history
    View official CMS source
    Skilled Nursing Facility Enrollments
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset identifier
    5f2c306f-3b1c-42cd-b037-187b2ce22126
    Source updated
    Jul 27, 2026
    Retrieved
    Aug 15, 2026
    Supports
    Ownership parties, organization connections, and ownership history
    View official CMS source
    Nursing Home Chain Performance Measures
    Source organization
    Centers for Medicare & Medicaid Services (CMS)
    Dataset identifier
    97ecfad1-d3f1-4d42-b774-d74661d830bc
    Coverage
    Wed Jul
    Source updated
    Aug 12, 2026
    Retrieved
    Aug 16, 2026
    Supports
    CMS chain context, performance, and monthly history
    View official CMS source
    Verified public facility information
    Source organization
    Public facility listing
    Dataset identifier
    commercial-corroboration:public-listing
    Source updated
    Aug 18, 2026
    Retrieved
    Aug 18, 2026
    Supports
    Independently verified public website, phone, or publicly used name. Not a CMS rating or regulatory status.
    How sources work

    No paid placements. Facilities cannot pay to rank higher. We cite. You decide.