Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Liberty Commons Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with chronic pain and multiple comorbidities received both an old and a new acetaminophen order simultaneously, resulting in a daily dose exceeding recommended limits. The error occurred when the Unit Manager entered a new order but failed to discontinue the previous one, and the facility's process for a second nurse check was not followed. The duplicate orders were not identified by pharmacy review or facility leadership until after administration.
A nurse administered Ativan, prescribed for another resident, to a resident who was not ordered this medication and was supposed to receive Oxycodone for pain. The error was discovered during a narcotic count, and it was found that the nurse had not verified the medication label before administration. The resident, who had no diagnosis of anxiety and was cognitively intact, did not receive the scheduled pain medication and instead received an unnecessary antianxiety drug.
Failure to Discontinue Previous Acetaminophen Order Resulted in Excessive Dosage
Penalty
Summary
A deficiency occurred when a resident with chronic pain syndrome, osteoarthritis, and type 2 diabetes mellitus with diabetic neuropathy received excessive doses of acetaminophen due to a failure to discontinue a previous medication order. The resident had an active care plan for pain management, and her physician initially ordered acetaminophen extended release 650 mg three times daily, not to exceed 3,000 mg in 24 hours. Subsequently, a new order was written for acetaminophen 1,000 mg twice daily, but the previous order was not discontinued, resulting in a combined daily dose of 3,950 mg. The medication administration record confirmed that both acetaminophen regimens were administered concurrently over a period of time. The error was traced to the Unit Manager, who entered the new order but did not discontinue the previous one, citing oversight. The facility's process for order entry and verification was not followed, as the second nurse check was omitted when the Unit Manager entered the order herself. This lapse allowed the duplicate orders to remain active and be administered to the resident. Interviews with pharmacy consultants, the nurse practitioner, and the DON confirmed that the recommended maximum daily dose of acetaminophen for elderly residents is 3,000 mg, and the error was not detected until after the resident had received the excessive dosage. The pharmacy's monthly review process did not identify the issue until after the orders had been corrected. The DON and Medical Director were unaware of the duplicate orders until after the incident, and the facility's standard procedures for order reconciliation and verification were not properly executed in this case.
Medication Error: Administration of Wrong Medication to Resident
Penalty
Summary
A medication error occurred when Nurse #1 administered Ativan, a medication prescribed for a different resident, to Resident #60, who was not prescribed Ativan and did not have a diagnosis of anxiety. Resident #60 had orders for Oxycodone 5 mg for pain management, but instead received Ativan 0.5 mg, which was intended for another resident. The error was discovered during the narcotic count at shift change, revealing that the wrong medication had been pulled and administered. Nurse #1 acknowledged that she failed to verify the medication label before administration, mistakenly assuming the last medication card in the narcotic lock box was the correct one for Resident #60. Resident #60 was cognitively intact and had diagnoses of diabetes type 2, hypertension, and atrial fibrillation. There were no orders for antianxiety medication for this resident, and the Minimum Data Set assessment confirmed no receipt of such medication. The incident was identified promptly, and the error was reported to the Director of Nursing, the former Medical Director, and Resident #60. The error resulted in Resident #60 not receiving the scheduled dose of Oxycodone as ordered, and receiving Ativan instead.
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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 Sanford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westfield Rehabilitation And Health Center | 3.8 mi | ★★★★★ | 6 | 0 |
| Sanford Health & Rehabilitation Co | 10.2 mi | ★★★★★ | 0 | 0 |
| Peak Resources - Pinelake | 17.5 mi | ★★★★★ | 1 | 0 |
| Emerald Health & Rehab Center | 17.6 mi | ★★★★★ | 2 | 0 |
| Lillington Health And Rehabilitation Center | 20 mi | ★★★★★ | 0 | 0 |
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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 August 2026) and official state health department websites.