Cycle 1
Health 2025-08-21 · Fire 2024-08-23
1 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
5 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Sanford, NC
Westfield Rehabilitation and Health Center
5-star overall rating with 4-star inspections with $12,735 in total fines with 1 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
3100 Tramway Road, Sanford, NC
(919) 775-5404
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
83
Certified beds
Average residents
79
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Liberty Senior Living
Operator or chain grouping
Approved since
1981-11-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
35 facilities
Chain averages 3 overall / 3 health / 2 staffing / 3 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.44
Registered nurse staffing · state 0.59 · national 0.68
LPN hours / resident day
0.91
Licensed practical nurse staffing · state 0.87 · national 0.87
Aide hours / resident day
2.20
Nurse aide staffing · state 2.33 · national 2.35
Total nurse hours
3.55
All reported nurse hours · state 3.78 · national 3.89
Licensed hours
1.36
RN + LPN hours · state 1.45 · national 1.54
Weekend hours
3.22
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.25
Weekend registered nurse coverage · state 0.38 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.43
CMS adjusted RN staffing hours
Adjusted total hours
3.45
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
25%
Annual RN turnover · state 48% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 50% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,816
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
10.30
Composite VBP score used to determine payment impact.
Payment multiplier
0.9809
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 21.03% · Performance 21.96% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
2.23
Baseline 8.80% · Performance 7.76% · Measure score 2.23 · Achievement 0 · Improvement 2.23
Total nurse turnover
1.89
Baseline 52.86% · Performance 55.95% · Measure score 1.89 · Achievement 1.89 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.01 hours · Performance 3.11 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.42% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 287 · Observed rate 11.15% · Lower 95% interval 8.58% |
| Discharge to community | 64.96% |
50.57%
14.4 pts better
|
Better than the National Rate · Eligible stays 273 · Observed rate 60.44% · Lower 95% interval 59.61% |
| Medicare spending per beneficiary | 0.92 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 99.39% |
95.27%
4.1 pts better
|
Numerator 164 · Denominator 165 |
| Falls with major injury | 1.21% |
0.77%
0.4 pts worse
|
Numerator 2 · Denominator 165 |
| Discharge self-care score | 54.62% |
53.69%
0.9 pts better
|
Numerator 71 · Denominator 130 |
| Discharge mobility score | 59.23% |
50.94%
8.3 pts better
|
Numerator 77 · Denominator 130 |
| Pressure ulcers or injuries, new or worsened | 2.42% |
2.29%
0.1 pts worse
|
Numerator 4 · Denominator 165 · Adjusted rate 1.8% |
| Healthcare-associated infections requiring hospitalization | 7.76% |
7.12%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 171 · Observed rate 7.6% · Lower 95% interval 4.9% |
| Staff COVID-19 vaccination coverage | 17.02% |
8.2%
8.8 pts better
|
Numerator 16 · Denominator 94 |
| Staff flu vaccination coverage | 34.62% |
42%
7.4 pts worse
|
Numerator 36 · Denominator 104 |
| Discharge function score | 60% |
56.45%
3.5 pts better
|
Numerator 78 · Denominator 130 |
| Transfer of health information to provider | 95.28% |
95.95%
0.7 pts worse
|
Numerator 121 · Denominator 127 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 13.51% |
25.2%
11.7 pts worse
|
Numerator 10 · Denominator 74 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
1.8
0.9 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.8 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
1.8
0.9 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.8 · Expected 1.5 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 98.3% |
91.5%
6.8 pts better
|
93.4%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 96.3% · Q2 100.0% · Q3 100.0% · Q4 96.7% · 4Q avg 98.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.1%
5.9 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.6% |
3.6%
1 pts better
|
3.3%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 1.7% · Q4 6.6% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.9% |
4.8%
3.9 pts better
|
11.4%
10.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.8% · Q3 0.0% · Q4 1.8% · 4Q avg 0.9% |
| Percentage of long-stay residents who lose too much weight | 4.2% |
7.2%
3 pts better
|
5.4%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 6.7% · Q3 2.0% · Q4 0.0% · 4Q avg 4.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 5.2% |
21.6%
16.4 pts better
|
19.6%
14.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.2% · Q3 10.2% · Q4 7.1% · 4Q avg 5.2% |
| Percentage of long-stay residents who received an antipsychotic medication | 14.2% |
15.0%
0.8 pts better
|
16.7%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.2% · Q2 22.5% · Q3 13.3% · Q4 6.4% · 4Q avg 14.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 15.9% |
21.5%
5.6 pts better
|
16.3%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q3 12.6% · Q4 11.1% · 4Q avg 15.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.0% |
16.8%
3.8 pts better
|
14.9%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.8% · Q2 16.3% · Q3 6.2% · Q4 16.4% · 4Q avg 13.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 2.0% |
0.9%
1.1 pts worse
|
1.0%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 2.7% · Q3 2.4% · Q4 1.3% · 4Q avg 2.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
2.6%
0.9 pts better
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.1% · Q3 1.7% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.8% |
21.2%
8.6 pts worse
|
19.8%
10 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 40.3% · Q2 26.1% · Q3 33.1% · Q4 20.1% · 4Q avg 29.8% |
| Percentage of long-stay residents with pressure ulcers | 2.4% |
6.0%
3.6 pts better
|
5.1%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 2.5% · Q3 0.0% · Q4 1.3% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.0% |
79.9%
16.1 pts better
|
81.7%
14.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 94.9% · Q2 97.1% · Q3 96.5% · Q4 95.5% · 4Q avg 96.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.3% |
13.2%
3.1 pts worse
|
12.0%
4.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.3% · Observed 14.6% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.4% |
1.5%
0.1 pts better
|
1.6%
0.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 2.5% · Q3 1.7% · Q4 0.8% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.5% |
78.1%
17.4 pts better
|
79.7%
15.8 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.5% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 23.6% |
22.9%
0.7 pts worse
|
23.9%
0.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 23.6% · Observed 19.7% · Expected 19.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-23 · Fire 2023-03-09
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-03-09 · Fire 2021-07-01
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2024-08-23
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-08-02
D · Potential for more than minimal harm
2024-08-23
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-08-02
D · Potential for more than minimal harm
2024-08-23
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-08-02
D · Potential for more than minimal harm
2024-08-23
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-08-02
D · Potential for more than minimal harm
2024-08-23
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-08-02
D · Potential for more than minimal harm
2023-03-09
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-04-13
D · Potential for more than minimal harm
2023-03-09
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-04-13
D · Potential for more than minimal harm
2023-03-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-13
Inspection history
Recent health citations
G · Actual harm
2025-08-21
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Not marked corrected
D · Potential for more than minimal harm
2024-08-23
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-09-30
D · Potential for more than minimal harm
2024-08-23
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2024-08-20
E · Potential for more than minimal harm
2023-03-09
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-03-28
E · Potential for more than minimal harm
2023-03-09
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-04-15
E · Potential for more than minimal harm
2023-03-09
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-04-15
E · Potential for more than minimal harm
2023-03-09
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-04-15
D · Potential for more than minimal harm
2023-03-09
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-03-28
D · Potential for more than minimal harm
2023-03-09
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-04-14
D · Potential for more than minimal harm
2023-03-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-04-14
D · Potential for more than minimal harm
2023-03-09
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-04-15
B · Minimal harm
2023-03-09
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2023-04-14
Penalties and ownership
What sits behind the stars
$12,735
2025-08-21
Fine
Fine · fine $12,735
Fine
Ownership
Long Term Care Management Services LLC
5% Or Greater Direct Ownership Interest · Organization
Mcneill, John
5% Or Greater Indirect Ownership Interest · Individual
Mcneill, Ronald
5% Or Greater Indirect Ownership Interest · Individual
Bork, Matthew
Operational/Managerial Control · Individual
Calcutt, Joeseph V
Operational/Managerial Control · Individual
Hamric, Anthony
Operational/Managerial Control · Individual
Liberty Healthcare Management Inc
Operational/Managerial Control · Organization
Liberty Long Term Care LLC
5% Or Greater Direct Ownership Interest · Organization
Long Term Care Management Services LLC
Operational/Managerial Control · Organization
Mcneill, John
5% Or Greater Direct Ownership Interest · Individual
Mcneill, John
Operational/Managerial Control · Individual
Mcneill, John
Corporate Director · Individual
Mcneill, Ronald
5% Or Greater Direct Ownership Interest · Individual
Mcneill, Ronald
Operational/Managerial Control · Individual
Mcneill, Ronald
Corporate Director · Individual
Miller, Robert
Corporate Director · Individual
Mitchell, Rajan
Operational/Managerial Control · Individual
Mitchell, Rajan
Corporate Director · Individual
Osano, Patience
Operational/Managerial Control · Individual
Purifoy, Penny
Operational/Managerial Control · Individual
Wilson, Jeffrey
Operational/Managerial Control · Individual
Wilson, Jeffrey
Corporate Director · Individual
Wilson, Jeffrey
W-2 Managing Employee · Individual
Nearby options
Other facilities in reach
#1
Liberty Commons Nursing and Rehabilitation Center
Sanford, NC
3-star overall rating with 4-star inspections with 2 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Sanford Health & Rehabilitation Co
Sanford, NC
4-star overall rating with 4-star inspections with $10,527 in total fines with 1 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Peak Resources - Pinelake
Carthage, NC
4-star overall rating with 4-star inspections with $7,901 in total fines with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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