Average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Liberty Commons Nsg And Rehab Ctr Of Rowan County during CMS and state inspections, most recent first.
Surveyors identified deficiencies in food storage and kitchen sanitation, including unlabeled and spoiled food in the walk-in cooler and freezer, a nonfunctional dish machine thermostat gauge with no alternative temperature monitoring, and an ice machine with a removable blackish film on its interior cover. Staff interviews confirmed awareness of these issues and lapses in proper procedures.
A resident's bathroom was found to have a persistent water leak from a cracked sink p-trap, resulting in repeated puddles on the floor over several days. Despite multiple staff members entering the bathroom, the leak went unreported and no wet floor signs were posted. The maintenance team was unaware of the issue until informed by management, and the resident using the bathroom had impaired cognition.
A visually impaired resident with multiple medical conditions was repeatedly unable to access the call bell, telephone, and water cup due to staff placing these items out of reach. The resident often had to yell for help or rely on a roommate to activate the call bell and answer the phone, resulting in missed calls and limited access to water. Staff interviews and observations confirmed that care plan interventions to keep essential items within reach were not consistently followed.
A resident with dysphagia and severe cognitive impairment was served a breakfast meal that did not meet the physician-ordered pureed consistency, receiving eggs and oatmeal that were not properly pureed. Staff interviews revealed a lack of adherence to dietary recipes and inconsistent understanding of pureed diet requirements, resulting in the resident not receiving the prescribed therapeutic diet.
A resident with legal blindness and multiple medical conditions did not consistently receive meals in bowls or preferred foods as ordered, making self-feeding difficult. Staff were unaware of the resident's specific dietary needs, and meal tickets were confusing, resulting in food being served on plates and only one milk provided instead of two. The resident missed preferred foods and struggled to eat independently due to these failures.
The facility failed to maintain a safe and sanitary environment, with issues in shower rooms and residents' wheelchairs. Two shower rooms had cleanliness and maintenance problems, including odors, debris, and damaged tiles. Residents' wheelchairs were found with dust and food crumbs, and there was no documentation of cleaning. Additionally, a resident's room had unrepaired wall damage, with no work orders submitted. Staff interviews revealed a lack of communication and documentation for maintenance and cleaning tasks.
A facility failed to complete a significant change in status MDS assessment for a resident readmitted with urine retention, chronic kidney disease, a UTI, a stage 3 pressure ulcer, and significant weight loss. The MDS Coordinator missed coding these changes, and the quarterly MDS inaccurately reported no weight loss or pressure ulcer risk.
Two residents experienced improper medication administration. One resident, with severe cognitive impairment, was found with a pill on her chest after a unit manager failed to confirm she swallowed it. Another resident, cognitively intact, had her medications left unattended on a bedside table by a nurse. Both incidents highlight a failure to adhere to professional standards in medication administration.
Deficiencies in Food Storage, Dishwashing, and Ice Machine Sanitation
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food storage and kitchen sanitation practices. In the walk-in cooler, there were several instances of opened and unlabeled food items, including a 5-pound bag of shredded cheese and a 5-pound bag of romaine lettuce showing signs of spoilage, such as discoloration and fluid accumulation. Additionally, a bag of diced strawberries was found with both an open and discard date that had already passed, and several bell peppers exhibited spoilage. In the walk-in freezer, open and unlabeled packages of chicken strips, hot dogs, sausage patties, and cookies were found with signs of dehydration, discoloration, and leathery spots. Staff interviews confirmed awareness of improper storage and spoilage, with acknowledgment that labeling and dating procedures were not consistently followed. Further deficiencies were identified with the dishwashing process. The dish machine's washing thermostat gauge was found to be nonfunctional, consistently freezing at 120 degrees and failing to register temperature changes during multiple wash cycles. Dietary staff reported that the issue had persisted for over a week, and there was no alternative method in place to verify dishwashing temperatures. The Dietary Manager was aware of the malfunction, and the dish machine, which was rented from an outside vendor, had ongoing issues that had not been resolved. Additionally, the kitchen's ice machine was found to have a white interior cover coated with a blackish film-like substance, which could be removed by touch, indicating a lack of cleanliness. The Dietary Manager and Assistant Dietary Manager acknowledged the presence of the residue and stated that the ice machine would not be used until it was serviced. The Administrator confirmed expectations for cleanliness and that the ice machine would remain out of use until cleaned.
Failure to Maintain Clean and Safe Bathroom Environment Due to Unaddressed Sink Leak
Penalty
Summary
The facility failed to maintain a clean and homelike environment by not addressing a leaking sink drain in one of the shared bathrooms used exclusively by a resident. Over the course of several days, surveyors observed increasing puddles of clear liquid, identified as water, accumulating on the bathroom floor beneath and in front of the sink. The leak originated from a cracked p-trap under the sink, which was confirmed by the Director of Maintenance upon inspection. The water leak was not reported or noticed by housekeeping staff, nurse aides, or nursing staff during their routine duties, despite the presence of water on the floor during multiple observations. No wet floor signs were displayed to warn of the hazard during this period. Interviews with staff revealed that the maintenance team was unaware of the issue until it was brought to their attention by surveyors. The facility's process for reporting maintenance issues involved staff filling out a work order and placing it in a designated box, or verbally notifying maintenance for urgent matters. However, in this instance, none of the staff who entered the bathroom reported the leak, and the maintenance worker only became aware of the problem after being informed by the Director of Maintenance. The resident using the bathroom had impaired cognition and sometimes used the bathroom independently, which could have increased the risk of harm due to the unaddressed water leak.
Failure to Provide Accessible Call Bell, Telephone, and Water for Visually Impaired Resident
Penalty
Summary
The facility failed to provide necessary accommodations for a visually impaired resident, resulting in the resident's inability to consistently access essential items such as the call bell, telephone, and water cup. Multiple observations revealed that the call bell was frequently placed out of the resident's reach, often left on a recliner behind him or across his bed, making it inaccessible when he was in his wheelchair. The resident, who was legally blind and had a history of falls, was observed attempting to locate the call bell by reaching and patting around but was unable to find it. Staff interviews confirmed that the call bell was routinely placed in locations the resident could not access independently, and the resident often had to yell for assistance or rely on his roommate to activate the call bell. The resident also experienced difficulty accessing his telephone, with observations showing that multiple cordless phones were out of his reach, resulting in numerous missed calls. The resident expressed frustration at being unable to answer the phone himself and indicated that his roommate frequently answered calls for him. Additionally, the resident was unable to reach his water cup, which was placed on a bedside table out of his reach, and he was observed attempting unsuccessfully to access it. Staff interviews corroborated that the resident had trouble maneuvering around his room due to his visual impairment and the placement of furniture, further limiting his ability to reach necessary items. The care plan for the resident included interventions such as keeping the call bell and frequently used items within reach and advising the resident of their location. However, observations and staff interviews demonstrated that these interventions were not consistently implemented. Staff acknowledged placing items out of the resident's reach and relying on the roommate to assist, rather than ensuring the resident's independent access to essential items as outlined in the care plan.
Failure to Provide Physician-Ordered Pureed Diet
Penalty
Summary
A deficiency occurred when a resident with diagnoses including dysphagia, vascular dementia, and decreased appetite, who was severely cognitively impaired and required a pureed diet with thick liquids, was served a breakfast meal that did not meet the prescribed pureed consistency. The resident's care plan and physician's order specified a pureed texture and thick liquids, and the meal ticket reflected these requirements. However, during observation, the resident was served eggs with a baked cheese topping and regular consistency oatmeal with visible oats, neither of which met the pureed standard as defined by facility recipes and staff descriptions. Interviews with nursing and dietary staff revealed inconsistencies in understanding and preparing pureed diets. The nurse assisting the resident believed the meal was appropriate, despite the eggs and oatmeal not being pureed. Dietary staff admitted to not pureeing the eggs due to concerns about texture and stated that oatmeal was never pureed, contrary to recipe instructions. The dietary manager confirmed that the recipe for pureed eggs and oatmeal was not followed and that the resident should have received a pureed meal as ordered. Further, the DON verified that the eggs were not of pureed consistency and stated that discrepancies in meal preparation should be reported, but she was not notified of the issue. The administrator acknowledged that residents must receive the physician-prescribed diet and consistency. The failure to provide the correct food texture was confirmed through direct observation, staff interviews, and review of dietary procedures and documentation.
Failure to Provide Special Eating Equipment and Dietary Orders for Visually Impaired Resident
Penalty
Summary
The facility failed to provide meals in accordance with a resident's care plan and dietary orders, specifically for a resident with visual impairment and legal blindness. The resident's care plan and diet order required all food to be served in bowls to facilitate self-feeding, as well as the provision of two cartons of milk with lunch and avoidance of whole sandwiches. Observations revealed that the resident was served food items on plates, such as a whole cheese sandwich and cake, rather than in bowls as ordered. The resident expressed difficulty eating from plates and handling whole sandwiches due to his visual impairment. Additionally, the resident consistently received only one carton of milk with meals, contrary to the dietary order for two cartons. Staff interviews indicated a lack of awareness of the resident's specific needs, with one nurse stating she was unaware of the requirement for all food to be in bowls. The dietary manager acknowledged that staff made mistakes and that the tray card was confusing, leading to errors in meal preparation and delivery. The posted instructions above the resident's bed and on the tray card were not consistently followed, resulting in the resident missing preferred foods and experiencing difficulty feeding himself.
Facility Fails to Maintain Sanitary Environment and Equipment
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in several areas, including two shower rooms and multiple residents' wheelchairs. In the 200 hall shower room, a rancid odor was present, and the room had several maintenance issues, such as a loosely attached toothbrush holder, debris-covered floor drain, cracked tiles, and missing tiles. The 300 hall shower room also had cleanliness issues, including a missing trash can liner, rusted faucet handle, and debris on the floor. Both shower rooms had thick dirt and debris in the tile grout, indicating a lack of proper cleaning and maintenance. The facility also failed to ensure the cleanliness of residents' wheelchairs. Observations revealed that the wheelchairs of four residents were covered with thick gray dust and food crumbs. The facility had a schedule for cleaning wheelchairs, but there was no documentation to confirm whether the cleaning was completed. Staff interviews indicated that while there was an expectation for wheelchairs to be cleaned, there was no system in place to verify or report the completion of these tasks. Additionally, the facility did not address maintenance concerns in a resident's room, where the wall behind the bed had dried adhesive, gouges, and missing paint. The resident's family reported that a plastic wall protector had fallen off and had not been replaced, despite being reported to staff. The maintenance director and assistant were unaware of the issue, and no work orders had been submitted for the necessary repairs. The administrator expected rooms to be in good repair, but the lack of communication and documentation led to unresolved maintenance issues.
Failure to Complete Significant Change MDS Assessment
Penalty
Summary
The facility failed to complete a comprehensive significant change in status Minimum Data Set (MDS) assessment for a resident who was readmitted with diagnoses including urine retention and chronic kidney disease. Upon readmission, the resident had a urinary tract infection, a stage 3 pressure ulcer on the sacrum, and a urinary catheter. Additionally, the resident experienced a weight loss of 10% or greater in the last 180 days. Despite these significant changes, the quarterly MDS assessment inaccurately reported no weight loss or gain and failed to address the pressure ulcer. The MDS Coordinator acknowledged missing these critical areas and not completing a significant change in status MDS assessment upon the resident's readmission. The facility administrator expected such assessments to be completed in a timely manner.
Failure to Ensure Proper Medication Administration
Penalty
Summary
The facility failed to provide care according to professional standards when a unit manager did not ensure that a resident swallowed her medication before leaving the room. Resident #50, who was admitted with diagnoses including cerebral infarction and gastrostomy, was observed with a pill lying on her chest, indicating she had not swallowed it. The unit manager had administered the medication and believed the resident had swallowed it after taking several sips of water. However, the pill was later found on the resident's chest, suggesting she may have spit it out after the manager left the room. The Director of Nursing confirmed that the unit manager should have verified the resident swallowed the medication. Additionally, the facility failed to adhere to professional standards when a nurse left a medicine cup with pills unattended on Resident #13's bedside table. Resident #13, who was cognitively intact and had diagnoses including type 2 diabetes and chronic kidney disease, was in the bathroom when the nurse placed the medication on the table and left the room. The nurse acknowledged that she should have waited for the resident to return from the bathroom to administer the medications and that they should not have been left unattended. The Director of Nursing reiterated that medications should not be left unattended and should be administered directly to the resident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Salisbury
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Trinity Oaks | 2.9 mi | ★★★★★ | 0 | 0 |
| Piedmont Health & Rehab Center | 4.4 mi | ★★★★★ | 6 | 1 |
| The Laurels Of Salisbury | 4.8 mi | ★★★★★ | 1 | 0 |
| Salisbury Rehabilitation And Nursing Center | 4.9 mi | ★★★★★ | 17 | 1 |
| Nc State Veterans Home - Salisbury | 5.2 mi | ★★★★★ | 12 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.