Liberty Commons Nursing and Rehabilitation Center

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

57.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 35 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 36.4% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 22 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.17 therapist hours per resident per day in 2026Q1 — more than 15% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 1% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 80 beds and averages 74.8 residents a day — about 94% occupied, or roughly 5 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 3.17 hrs/resident/day is below the 3.48-hour benchmark and RN staffing of 0.31 is below the 0.55-hour RN benchmark and nurse-aide staffing of 1.82 is below the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 2.93 hrs/resident/day on weekends vs 3.26 on weekdays — 10% thinner on weekends. RN hours go from 0.33 to 0.27 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 70% is well above the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

34 citations, most serious first. The 16 most serious are shown; the remaining 18 are one tap away and print in full.

• Immediate jeopardy · K2023-02-09 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — pattern
  Provide appropriate pressure ulcer care and prevent new ulcers from developing.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation and interviews with Orthopedic Physician Assistant (PA), Wound Nurse, Wound Physician, Medical Director (MD) #2, Director of Nursing (DON) #2, Administrator #2, Nurse Practitioner (NP) #2 and family, the facility failed to prevent the development of a pressure ulcer, protect Resident #16's skin under an immobilizer used following a fractured distal femur (the area of the leg just above the knee joint), perform skin checks under the immobilizer and assess skin. At the first orthopedic follow up appointment, an abrasion was identified. Orders were given to pad an abrasion and consult with a wound physician. The orders were not implemented. Skin checks continued not to be done following the identification of the pressure ulcer. The area deteriorated to an unstageable pressure ulcer. An unstageable pressure ulcer means a full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by eschar (dry,…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · K2023-02-09 · tag F0835 — failed to run the facility competently — pattern
  Administer the facility in a manner that enables it to use its resources effectively and efficiently.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and Administrator #1 and Director of Nursing (DON) #1 interviews the facility administration failed to have effective systems in place to prevent, identify, assess, treat, and manage residents with and at risk for pressure sores. This failure resulted in Resident #16 developing an avoidable abrasion under her left leg immobilizer identified on 09/06/22 at an orthopedic consult visit. The abrasion went untreated and area deteriorated into an unstageable pressure ulcer (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) on 9/13/22. The Wound Physician resolved Resident #16's avoidable pressure ulcer on 1/10/23 with an order for 7 days of dressing changes to protect of the healed area. The lack of reassessment after 1/10/23 resulted in the Wound Physician being consulted on 1/24/23 where she observed the area had reopened into a stage 4 pressure ulcer (deep wound reaching the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Administration Deficiencies · Deficient, Provider has date of correction
• Immediate jeopardy · J2023-02-09 · tag F0580 — failed to tell family and doctor about changes — isolated
  Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and staff, Wound Nurse, Director of Nursing (DON) #2, Medical Director (MD) #2, and Nurse Practitioner (NP) #2 interviews, the facility failed to notify the MD #2 or NP #2 that Resident #16's developed an abrasion to her left lateral calf under her immobilizer on 9/6/22 resulting in no assessment or treatment until 9/13/22 when the area was discovered as an unstageable pressure ulcer (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar). The Wound Physician noted on 9/13/22 the pressure ulcer as measuring 10 centimeters (cm) by 5 cm with 5% of thick adherent black necrotic tissue (eschar) 80% thick adherent devitalized necrotic tissue (slough) and 15% granulation tissue. This was for 1 of 4 residents reviewed for pressure ulcers (Resident #16). Immediate jeopardy began on 09/06/22 when an abrasion to Resident #16's left lateral calf was identified underneath the leg immobilizer…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2023-02-09 · tag F0600 — failed to protect residents from abuse and neglect — isolated
  Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff family, emergency room (ER) Physician, Medical Director #2, Nurse Practitioner (NP) #1 interviews and record review, the facility failed to protect the resident from injury of unknown origin (right proximal tibia/fibula fracture) resulting in physical harm. This was for 1 (Resident #16) of 8 residents reviewed for accidents. The findings included: Resident #16 was admitted on [DATE] with cumulative diagnoses of Dementia, Congestive Heart failure, Chronic Kidney Disease, Coronary Artery Disease, and osteoporosis. Review of Resident #16's care plan included a care plan for osteoporosis with a risk for fractures dated last revised on 7/9/21. Interventions included observation, document and report any signs or symptoms of an acute fracture, compression fractures, loss of height and complaints of back pain. Resident #16 was also care planned on 9/11/19 for an actual fall and the interventions included two staff assist with transfers dated 10/23/19. The quarterly Minimum Data Set (MDS) dated [DATE]…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Freedom from Abuse, Neglect, and Exploitation Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2023-02-09 · tag F0626 — isolated
  Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and Hospital Case Manager, Ombudsman, Business Office Manager, Regional Director, Former Administrator, and current Administrator interviews, the facility failed to permit a resident to return to the facility following a facility-initiated transfer to the hospital for 1 of 1 resident reviewed for hospital transfer. Resident #106 was medically stable to return on [DATE] when the facility refused to readmit the resident. The resident remained in the hospital until [DATE] where she expired. Based on the reasonable person concept a resident transferred to the hospital for an acute condition expects to return to their home at the facility following stabilization at the hospital. Refusal to permit the resident's return and the resident's subsequent 23 day stay at the hospital following stabilization would cause a reasonable person to experience a negative psychosocial outcome that would include feelings of anxiety, fear, frustration, and/or a depressed mood. The findings included: Resident #106…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Actual harm · G2023-02-09 · tag F0689 — failed to keep residents free of avoidable accidents; supervise adequately — isolated
  Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews and record review, the facility failed to prevent a fall on 8/16/22 for a resident with cognitive impairment and poor decision-making skills who required extensive staff assistance with bed mobility and positioning for 1 (Resident #16) of 8 residents reviewed for accidents. Resident #16's rolled from her side onto the floor resulting in a left femur fracture. The bed was in the high position while Nursing Assistant (NA) #11 left the room to throw dirty linens in the laundry bin outside the resident's room. The findings included: Resident #16 was admitted on [DATE] with cumulative diagnoses of Dementia, Congestive Heart failure, Chronic Kidney Disease, Coronary Artery Disease, and osteoporosis. The quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #16 had severe cognitive impairment, required extensive assistance with bed mobility, transfers and personal hygiene. Resident#16 was care planned on 9/11/19 and last revised on 8/16/22 for an actual fall with a…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Past Non-Compliance
• Potential for harm · E2025-05-05 · tag F0760 — failed to prevent significant medication errors — pattern
  Ensure that residents are free from significant medication errors.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, staff interviews, Pharmacy Consultants, Nurse Practitioner (NP), and Medical Director interviews, the facility failed to discontinue a medication per physician's order resulting in the resident receiving the previous ordered dose of acetaminophen (used to relieve mild to moderate pain) and the newly ordered dose of acetaminophen. This was for 1 of 5 residents (Resident #27) reviewed for unnecessary medications. The findings included: Resident #27 was admitted to the facility on [DATE] with diagnoses that included chronic pain syndrome, osteoarthritis, and type 2 diabetes mellitus with diabetic neuropathy. The quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #27's cognition was intact. She received routine pain medications, no PRN (as needed) pain medications, and reported pain frequently at a rating of 8 out of 10. Resident #27's active care plan, last reviewed 2/14/25, included the focus area of pain. The interventions included, in part, administer medication…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2025-05-05 · tag F0658 — failed to meet professional standards of care — isolated
  Ensure services provided by the nursing facility meet professional standards of quality.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews, and former Medical Director and staff interviews, the facility failed to prevent a medication error when Nurse #1 administered Ativan ( a medication used to treat anxiety) to Resident #60 that had been prescribed for Resident #57. This deficient practice affected 1 of 5 residents reviewed for unnecessary medications (Resident #60). The findings included: Resident #60 was admitted to the facility on [DATE] with diagnoses of diabetes type 2, hypertension and atrial fibrillation. Resident #60 did not have a diagnosis of anxiety. A quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #60 was cognitively intact and did not receive antianxiety medication. A review of Resident #60's March 2025 physician orders included an order for Oxycodone 5 mg one tablet by mouth four times a day for pain. There were no orders for Ativan. A review of Resident #57's physician orders included an order dated 1/28/25 for Ativan 0.5 milligrams (mg) every 24 hours as needed for fourteen…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-04-04 · tag F0791 — failed to provide routine dental services — pattern
  Provide or obtain dental services for each resident.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff, Nurse Practitioner (NP) #1 interviews and record review, the facility failed to follow dental consult Physician order dated 2/28/24 for 1 (Resident #49) of 1 resident reviewed for dental services. The findings included: Resident #49 was admitted on [DATE] with cumulative diagnoses of cerebral vascular accident, hemiplegia, and acute gingivitis. Review of Resident #49's hospital Discharge summary dated [DATE] read he had poor dentition and bleeding gums. There was no recommended intervention except the use of an antiseptic mouthwash four times daily. Review of Resident #49's admission Physician orders dated 12/21/23 included an order for First-Mouthwash BLM Mouth/Throat Suspension (mouth rinse made of different medications used to relieve pain from mouth and throat sores) four times a day for gingivitis. Review of Resident #49's admission Minimum Data Set (MDS) dated [DATE] indicated he had severe cognitive impairment, exhibited no behaviors, was dependent on staff for all of his…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-04-04 · tag F0550 — failed to protect resident dignity and rights — isolated
  Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, resident, staff interviews and record review, the facility failed to promote dignity by not assisting a resident who required staff assistance with activities of daily living (ADLs) with the removal of facial hair. This was for 1 (Resident #38) 3 residents reviewed for ADLs. The findings included: Resident #38 was admitted to the facility on [DATE] with a diagnosis of osteomyelitis. The quarterly Minimum Data Set, dated [DATE] indicated Resident #38 was cognitively intact, exhibited no behaviors and she was dependent on staff for her personal hygiene. Review of Resident #38's revised care plan dated 2/14/24 read Resident #38 was resistant to Physician recommendations related to eating from the vending machine and not eating sugar free snacks, refusals of showers in the mornings and getting up out of the bed. Resident #38 was also care planned last revised on 3/15/24 for staff assistance with her personal hygiene. Review of Resident #38's electronic medical record and behaviors monitoring…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-04-04 · tag F0561 — failed to honor residents' choices — isolated
  Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff and responsible party (RP) interviews and record review, the facility failed to honor a resident dependent of staff assistance with his shower preference. This was for 1 of 1 residents (Resident #33) reviewed for choices. The finding included: Resident #33 was admitted on [DATE] with diagnoses of a subdural hemorrhage and aphasia (unable to speak). Review of Resident #33's admission Activity Review dated 5/10/23 completed with his RP read it was very important to Resident #33 to choose between a bed bath, sponge bath or a shower. The quarterly Minimum Data Set, dated [DATE] indicated Resident #33 had severe cognitive impairment, exhibited no behaviors and he was dependent of staff for bathing. Review of Resident #33's comprehensive care plan included a care area for assistance with his activities of daily living (ADLs) last revised 2/6/24. Interventions included his preference of showers on the shower bed initiated 8/10/23. Review of Resident #33's undated electronic Aide Care…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-04-04 · tag F0584 — failed to keep a safe, clean, comfortable home — isolated
  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.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews with residents and staff, the facility failed to maintain bedside tables free from dried spills and debris for two rooms (room [ROOM NUMBER] and 212), failed to repair a broken dresser drawer (room [ROOM NUMBER]) and failed to ensure a resident ' s bedpan was labeled and stored in a sanitary manner. This deficient practice affected 1 of 3 resident halls (200 Hall). The findings included: 1. An observation of room [ROOM NUMBER] on 04/01/24 at 12:32 PM revealed bed A bedside table had a dried yellowish hardened substance on base of table measuring approximately 1 x 2 inches. Also bed A and B bedside tables with built up black substance on 2 separate 2.5 x 2 inch triangle areas on the base of each table. room [ROOM NUMBER] was occupied with 2 residents at the time of the survey. Housekeeper #1 observed in room wiping the top of A bed bedside table. An observation of room [ROOM NUMBER] on 04/02/24 at 09:55 PM revealed a bedpan with a white powder like substance on the rim and the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Rights Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-04-04 · tag F0641 — isolated
  Ensure each resident receives an accurate assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 2. Resident #53 was admitted to the facility on [DATE] with diagnoses that included a stroke resulting in hemiplegia (weakness to one side of the body) and hemiparesis (paralysis to one side of the body) of the right dominant side. Resident #53's baseline care plan included a focus area initiated on 2/27/24 for Activities of Daily Living (ADL) self-care performance deficit related to intracranial hemorrhage with right hemiparesis. A review of the Occupational Therapy Evaluation dated 2/27/24 indicated Resident #53's right upper extremity had impaired range of motion. A review of Resident #53's admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #53 had moderately impaired cognition and required assistance from staff for ADLs. She was not coded with any range of motion deficits to the upper body. On 4/1/24 at 10:45 AM, an interview and observation were conducted with Resident #53. She was unable to lift or use her right arm or hand and used her left hand to gesture and write on the erasable…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-04-04 · tag F0644 — isolated
  Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews with staff, the facility failed to refer a resident (Residents #25) for a level II Preadmission Screening and Resident Review (PASRR) for a newly diagnosed serious mental illness for 1 of 2 residents reviewed for PASRR. The findings included: Resident #25 was admitted to the facility on [DATE] with diagnosis that included Bipolar Disease, Dementia, Parkinson's Disease, and seizure disorder. She was admitted with a level 1 PASRR as of 04/15/19 and no further screening was required unless a significant change occurred to suggest a diagnosis of mental illness. Record review revealed Resident #25 was diagnosed on [DATE] with bipolar disorder. There was no evidence a referral for a level II PASRR screening was completed following the identification of this new serious mental health diagnosis. Resident #25's annual Minimum Data Set, dated [DATE] indicated she was not currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-04-04 · tag F0677 — failed to help fully-dependent residents with daily care — isolated
  Provide care and assistance to perform activities of daily living for any resident who is unable.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews and record review, the facility failed to provide nail care to a resident dependent of staff assistance with his activities of daily living (ALDs). This was for 1 (Resident #49) of 4 residents reviewed for ADLs. The findings included: Resident #49 was admitted on [DATE] with cumulative diagnoses of cerebral vascular accident, right hemiplegia and prediabetes. The quarterly Minimum Data Set, dated [DATE] indicated severe cognitive impairment, he exhibited no behaviors and he was dependent on staff for all of his ADLs. Resident #49 was care planned on 12/22/23 and last revised 1/23/24 for an ADL self-care performance deficit related to an intercranial hemorrhage. Interventions included to check his nail length, trim and clean as necessary. Report any changes to the nurse. Review of Resident #49's March 2024 Physician orders included an order dated 12/22/23 for blood glucose checks twice daily for nutrition monitoring. This order was discontinued on 3/22/24 due to the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-04-04 · tag F0842 — failed to keep accurate, complete medical records — isolated
  Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and staff interviews, the facility failed to maintain complete and accurate medical records in the areas of dental (Resident #30), urology (Residents #160 and #36) and podiatry (Resident #36). This was for 3 of 21 resident records reviewed. The findings included: 1. Resident #30 was admitted to the facility on [DATE]. A review of Resident #30's physician orders included an order dated 1/4/24 for a dental consult on 1/5/24 at 10:00 AM. A review of Resident #30's electronic medical record (EMR) did not include any dental consult progress notes. On 4/2/24 at 9:35 AM, an interview occurred with the Director of Nursing (DON) who stated the dental consult from 1/5/24 was not located in the facility and she would reach out to the provider to get a copy faxed over. The DON further stated it was the receptionist's responsibility to upload consultations to the EMR, but she had recently departed the facility. The Administrator was interviewed on 4/2/24 at 3:46 PM and provided the dental consult note…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to LIBERTY SENIOR LIVING — 37 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

CMS files one row per role, so the 25 rows in the source record cover these 16 parties — each is shown once here with every role it holds. Nothing is omitted.

6 organizational owners listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

About 71% of this home’s resident-days are paid by Medicaid, which reimburses well below the cost of care in most states. Heavily Medicaid-dependent homes run on thinner budgets — a context worth holding next to the staffing and inspection record, not a fault in itself. This home reported $930K paid to related parties — landlords or management companies under common ownership — equal to about 14% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in NC