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.

65.0% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 149 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 42.4% 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 66 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 0.29 therapist hours per resident per day in 2026Q1 — more than 45% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 0% 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 107 beds and averages 95.4 residents a day — about 89% occupied, or roughly 12 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 3.86 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.30 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.58 is at or above 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 3.43 hrs/resident/day on weekends vs 4.03 on weekdays — 15% thinner on weekends. RN hours go from 0.34 to 0.20 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 62% is well above the national median of 45%. 1 administrator has left in the past year.

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.

27 citations, most serious first. The 18 most serious are shown; the remaining 9 are one tap away and print in full.

• Immediate jeopardy · K2024-07-26 · tag F0580 — failed to tell family and doctor about changes — pattern
  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 interviews with staff, Medical Director (MD) and Physician Assistant (PA), the facility failed to notify the physician when a resident had signs of Clostridium Difficile (C. difficile) that included persistent loose, watery, mushy, and odorous stool. From 2/9/24 through 2/27/24 the resident experienced these abnormal stools. The physician was notified on 2/13/24 of the abnormal stools, but was not made aware of the ongoing issue until 2/27/24 when it was brought to the nurse's attention by the resident's family member. Upon discharge from the facility on 2/28/2024, the resident was immediately transported by a family member directly to her Primary Care Physician's office where she was tested for C. Difficile, and the lab test was positive for C. Difficile on 2/29/2024. This deficient practice placed Resident #86 at risk for developing complications from C. difficile such as dehydration, skin breakdown, and death. The facility also failed to notify the physician when a resident was…

  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
• Immediate jeopardy · Kcited before2024-07-26 · tag F0684 — failed to provide proper treatment and quality of care — pattern
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  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 family, staff, Medical Director, and Physician Assistant interviews, the facility failed to comprehensively assess a resident who was presenting with signs of Clostridium Difficile (C. difficile) (According to the Centers for Disease Control and Prevention (CDC): C. difficile-is a highly contagious bacteria that causes diarrhea and inflammation of the colon and can be life-threatening; symptoms include 3 or more foul smelling watery stools a day lasting longer than 1 day, and abdominal cramping), to determine the cause of the watery stools, identify the seriousness of the symptoms, and implement effective interventions to treat repeat watery stools which started on 2/09/2024. Resident #86's bowel movement documentation sheets from the date of admission, 2/8/24, through the date of discharge, 2/28/24, revealed she was coded as having 23 loose and watery stools, 19 loose and mushy stools, 1 putty like stool and 5 normal stools. The resident was administered 13 doses of anti-diarrheal…

  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
• Actual harm · G2024-02-29 · tag F0686 — failed to prevent and treat pressure sores (bedsores) — isolated
  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, staff and the Senior Director of Compliance for the Orthopedic Office/Registered Nurse (RN) and Physician interviews, the facility failed to contact the Orthopedic office for clarification and instructions for removal of the orthopedic pneumatic (air pressure) boot, dressing changes and skin assessments on a resident's left ankle (Resident #7) after her follow-up appointment with the physician's assistant on 12/21/2023. Resident #7 developed deep tissue injuries (DTI) to the bottom of her left great toe, left lateral foot and left heel. This was for 1 of 3 residents reviewed for pressure ulcers. The findings included: The hospital discharge instructions for Resident #7 dated 12/14/2023 by the hospital Physician read in part that Resident #7 was admitted to the hospital with a displaced bimalleolar fracture (ankle fracture) of left lower extremity (LLE) and underwent a surgical repair on 12/5/2023 with a splint, with large bulky dressing and ace wrap applied postoperatively. She was…

  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
• Actual harm · Gcited before2024-02-29 · 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 record review, observations, staff and Physician interviews, the facility failed to provide incontinence care safely for a resident who was dependent on staff assistance for 1 of 4 residents reviewed for falls (Resident #1). On 1/2/24 Nurse Aide (NA) #6 was attempting to pull the brief out from under Resident #1 by turning him onto his side and pressing on his back for him to roll over resulting in the resident rolling off the side of the bed and landing on the floor on his left shoulder and neck. Resident #1 experienced pain on the left side of his neck at a level of 8 out of 10 (with 10 being the worst pain possible), cervicogenic headaches (a pain that develops in the neck and is felt in the head), and sustained a cervical neck strain of the left trapezius muscle (injury to the large muscle in the back that supports the head and neck caused from overstretching or trauma). The findings included: Resident #1 was admitted to the facility on [DATE]. His diagnoses included chronic combined systolic and…

  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
• Actual harm · Gcited before2024-02-29 · tag F0867 — failed to act on quality-improvement findings — isolated
  Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, record review, and staff, resident and Physician interviews the facility's Quality Assurance and Performance Improvement (QAPI) Program failed to maintain implemented procedures and effective monitoring of interventions the committee put into place following the recertification and complaint investigation survey of 5/4/2023 and the complaint investigation survey of 9/15/23. This was for one recited deficiency in the area of supervision to prevent accidents (F689). During the 5/4/2023 recertification and complaint investigation survey, deficient practice was cited for failing to provide incontinence care safely to a dependent resident when the resident fell off the bed during care and fractured her right femur (thighbone) in two places. During the complaint investigation survey of 9/15/2023, deficient practice was cited for failing to provide a bed bath safely to a dependent resident when the resident fell off the bed during care and fractured her left femur and tibia (shinbone). During the current complaint investigation survey of 2/29/2024, deficient practice…

  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
• Actual harm · Gcited before2023-09-15 · 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 record review, observations, staff and Physician interviews, the facility failed to provide a bed bath safely for a dependent resident for residents reviewed for falls. Resident #2 sustained a fall off the bed during care, fracturing her left femur (thighbone) and tibia (shinbone) for 1 of 2 residents reviewed for falls (Resident #2). The findings included: Resident #2 was admitted to the facility on [DATE] with diagnoses which included in part: history of stroke, blindness, right below knee amputation, left sided paralysis and left lower extremity contracture. Review of the care plan initiated on 11/15/18 and revised on 4/13/23 for Resident #2 revealed a plan of care for activities of daily living (ADL) self-care performance deficit related to dependence. The following intervention was listed for Resident # 2's care plan: I am totally dependent on staff with 2-person assistance for repositioning and turning in bed. Review of the 7/19/23 quarterly Minimum Data Set (MDS) assessment revealed Resident # 2…

  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
• Actual harm · Gcited before2023-09-15 · tag F0867 — failed to act on quality-improvement findings — isolated
  Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review, observations, and staff and physician interviews, the facility's Quality Assurance and Performance Improvement (QAPI) Program failed to maintain implemented procedures and effective monitoring of interventions the committee put into place following the recertification and complaint investigation survey of 5/4/23. This was for one recited deficiency in the area of supervision to prevent accidents (F689). During the 5/4/23 survey, deficient practice was cited for failing to provide incontinence care safely to a dependent resident when the resident fell off the bed during care and fractured her right femur (thighbone) in two places. During the current complaint investigation survey of 9/15/23, deficient practice was cited for failing to provide a bed bath safely to a dependent resident when Resident #2 fell off the bed during care and fractured her left femur and tibia (shinbone). The continued failure during two federal surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assurance program. Findings included: This tag is…

  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
• Actual harm · Gcited before2023-05-04 · 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 record review, observations, staff and Physician interviews, the facility failed to provide incontinence care safely for a dependent resident (Resident #59) for 1 of 2 residents reviewed for falls. Resident #59 rolled off the bed during care, fracturing her right femur in two places. The findings included: Resident #59 was admitted to the facility on [DATE] with diagnoses to include cerebral infarction (stroke), vascular dementia, and severe aphasia (language disorder caused by damage in a specific area of the brain that controls language expression and comprehension). Review of the care plan initiated on 06/21/2019 and reviewed on 01/31/2023 for Resident #59 revealed a plan of care for activities of daily living (ADL) self-care performance deficit related to stroke. The following intervention was listed for Resident #59: I am totally dependent on staff for repositioning and turning in bed. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #59 was severely cognitively…

  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 · Ecited before2025-07-10 · tag F0761 — failed to label and store drugs safely — pattern
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on observations, record review and staff interviews, the facility failed to discard expired medications stored for use and discard loose pills observed in 3 of 5 medication (med) carts (the 200 hall, 400 hall and 600 hall medication carts) and failed to discard expired medications stored in 2 of 3 medication storage rooms (100 hall and 300 hall) reviewed for medication storage. Findings included:a. An observation was conducted on 7/9/25 at 8:39 AM of the 200 hall med cart in the presence of Medication Aid (MA #1), The observation revealed the following medications were stored on the cart. - A fluticasone propionate/salmeterol inhaler opened on 6/2/25 and expired 30 days after opening on the box. - There were 3 loose pills in the drawers of the cart (1 white oblong pill and 2 white round pills).An interview was conducted with MA #1 on 7/9/25 at 8:39 AM. MA #1 stated there should not be any expired medications or loose pills on the chart.b. An observation was conducted on 7/9/25 at 11:51 AM of the 400 hall cart in the presence of Nurse #5. The observation revealed there were 2…

  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 · E2025-07-10 · tag F0842 — failed to keep accurate, complete medical records — pattern
  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 review, and staff, Wound Physician, and Nurse Practitioner interviews, the facility failed to maintain accurate medical records by 1.) not documenting the administration of wound care to an unstageable sacral wound on the Treatment Administration Record (TAR) or in the electronic medical record and not accurately documenting the assessment of an implanted device (a device placed under the skin typically in the chest wall and used for long term intravenous (IV) access) for Resident #49. 2.) not accurately documenting that an antihypertensive medication (Hydralazine 25 milligrams) was held for systolic blood pressure less than 125 mmHg (millimeters of mercury) according to the physician orders (Resident #28). 3.) not accurately documenting the removal of a dressing from an arterial/venous (A/V) dialysis shunt (Resident #55). This occurred for 3 of 3 residents whose medical records were reviewed. Findings included: 1a.) A physician’s order dated 1/3/25 for Resident #49 revealed Dakins solution 0.5%…

  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 before2025-07-10 · 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 Based on record review and staff interviews, the facility failed to code the Minimum Data Set (MDS) accurately in the areas of fluid intake per day by intravenous (IV) or tube feeding and the use of antipsychotic medication on a daily basis for 1 of 24 residents whose MDS assessments were reviewed (Residents #91).The findings included:Resident #91 was admitted to the facility on [DATE] with diagnoses that included, in part, Alzheimer's disease, dementia without psychotic disturbance or mood disturbance, anorexia, and dysphagia.Review of Resident #91's quarterly Minimum Data Set assessment dated [DATE] documented she had an average fluid intake per day by IV or tube feeding of 501 cc (cubic centimeter)/day or more while a resident and also during the entire 7 days (of the look back period). It also noted antipsychotic medications were received on a routine basis.Review Resident #91's May 2025 and June 2025 electronic Medication Administration Records (eMAR's) revealed she had not been administered an…

  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 · D2025-07-10 · tag F0692 — failed to prevent malnutrition and dehydration — isolated
  Provide enough food/fluids to maintain a resident's health.
  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, Registered Dietitian and Nurse Practitioner interviews, the facility failed to address a Registered Dietitian recommendation to obtain weekly weights for 1 of 4 residents reviewed for nutrition (Resident # 75). Findings included: Resident #75 was admitted on [DATE] with medical diagnosis including chronic kidney disease, hypertension, and prostate cancer. Review of Resident #75's physician orders revealed an order dated 5/1/25 for Cardiac diet, Soft & Bite Sized texture with thin consistency liquids. Review of Resident #75's electronic health record revealed the following weights recorded: 5/2/25 194.8 pounds (Lb.)5/3/25 196.6 lb.5/10/25 No weight recorded Review of Resident #75's care plan dated 5/5/25 indicated a nutritional problem or potential nutritional problem related to receives a therapeutic, mechanically altereddiet, chronic kidney disease and dementia. Interventions included observe for, record and report to the physician as needed significant weight loss (3lbs in 1…

  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 · D2025-07-10 · tag F0698 — failed to provide proper dialysis care — isolated
  Provide safe, appropriate dialysis care/services for a resident who requires such services.
  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, record review, and staff and Nurse Practitioner interviews, the facility failed to: remove an ordered pressure dressing to a newly inserted arterial/venous (A/V) dialysis shunt site 4-6 hours after the resident returned from dialysis, check the resident's arterial/venous dialysis shunt when resident returned from dialysis and clarify orders that were entered inaccurately. This was for 1 of 1 resident (Resident #55) reviewed for dialysis. Findings included: Resident #55 was admitted to the facility on [DATE]. Diagnoses included end stage renal disease requiring hemodialysis (a treatment needed for residents with poor kidney function), and insertion of A/V dialysis shunt (a passage that is inserted in the body to allow fluid from one part of the body to another and used as an access port to dialyze residents) to left arm. A review of the physician orders revealed an order written on 03/20/25 for hemodialysis on Tuesday, Thursday, Saturday at 5:30 AM and an order to check Permacath (a special…

  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 · F2024-07-26 · tag F0727 — failed to provide required RN coverage — widespread
  Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record reviews and staff interview, the facility failed to schedule a Registered Nurse (RN) for at least 8 consecutive hours 12 of 122 days reviewed. The days included 06/10/23, 06/11/23, 06/24/23, 07/02/23, 07/09/23, 07/23/23, 10/29/23, 11/11/23, 11/12/23, 11/18/23, 11/19/23, and 11/26/23. Findings included: A review of the facility's daily schedules for the month of June 2023, July 2023 and from October 1, 2023, through November 30, 2023, was conducted on 07/26/24. The daily schedules indicated the resident census ranged from 75 to 88 from June 2023 through November 2023. The daily schedules revealed a Registered Nurse (RN) was not scheduled for at least 8 consecutive hours a day on the following dates: 06/10/23, 06/11/23, 06/24/23, 07/02/23, 07/09/23, 07/23/23, 10/29/23, 11/11/23, 11/12/23, 11/18/23, 11/19/23, and 11/26/23. An interview was conducted on 07/26/24 at 12:55 PM with the facility 's Administrator. During the interview, inquiry was made in regards to the RN hours indicated on the staffing schedule. The Administrator reported she was aware RN coverage was 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.

  Nursing and Physician Services Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-07-26 · tag F0756 — failed to review each resident's drug regimen — pattern
  Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
  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, Pharmacist Consultant and Physician interviews the Pharmacy Consultant failed to identify that a resident (Resident #59) received 10 units of Novolog Insulin before meals for diabetes for an order to hold if glucose (blood sugar level) was less than 120 milligrams per deciliter (mg/dl) 10 times during two monthly drug regimen reviews (June 2024 and July 2024) for 1 of 5 residents reviewed for unnecessary medications. Findings included: Resident #59 was admitted to the facility on [DATE]. Diagnoses included type 2 diabetes mellitus. The Minimum Data Set quarterly assessment dated [DATE] revealed Resident #59 was cognitively intact and she received insulin and hypoglycemic (medications to treat diabetes) medications. A review of the Physician's order revealed an order was written for Novolog Insulin, inject 10 units subcutaneously with meals and hold if glucose is less than 120 mg/dl. A review of the June 2024 Medication Administration Record revealed an order Novolog…

  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 · E2024-07-26 · tag F0757 — failed to avoid unnecessary drugs — pattern
  Ensure each resident’s drug regimen must be free from unnecessary drugs.
  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, Pharmacist Consultant and Physician interviews the facility failed follow a physician's order when a resident (Resident #59) received 10 units of Novolog Insulin before meals for diabetes when the order read to hold if glucose (blood sugar level) was less than 120 milligrams per deciliter (mg/dl). Resident received the medication 6 times between June 22, 2024, and July 24, 2024, for 1 of 5 residents reviewed for unnecessary medications. Findings included: Resident #59 was admitted to the facility on [DATE]. Diagnoses included type 2 diabetes mellitus. The Minimum Data Set quarterly assessment dated [DATE] revealed Resident #59 was cognitively intact and she received insulin and hypoglycemic (medications to treat diabetes) medications. A review of the physician's order revealed an order was written for Novolog Insulin, inject 10 units subcutaneously with meals and hold if glucose is less than 120 mg/dl. A review of the June 2024 Medication Administration Record revealed…

  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 · E2024-07-26 · tag F0880 — failed to prevent and control infections — pattern
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  Based on record review, observations and staff interviews, the facility failed to maintain infection control prevention by: (1) touching medications with bare hands during medication preparation for 1 of 3 medication administration observations completed; and (2) failed to follow enhanced barrier precautions while caring for a resident ' s feeding tube for 1 of 2 residents observed for tube feeding care (Resident #37 ). Finding Included: The facility policy for Medication Administration effective 12/2023 under Administration of Oral Medications reads: Never touch pills or tablets with bare hands. 1) During an observation of a medication administration pass on 07/23/24 at 8:46 am Medication Aide #4 was observed handling the following medications with her bare hands: Lasix, Protonix, Docusate, Carvedilol, Micro K, Preservision, and Zoloft. She popped the pills out of the bubble packs into her bare hand then placed them in a medication cup. She was not observed to use hand sanitizer or wash her hands prior to preparing the medications. During medication preparation she touched 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.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Ecited before2024-02-29 · tag F0684 — failed to provide proper treatment and quality of care — pattern
  Provide appropriate treatment and care according to orders, resident’s preferences and goals.
  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 observation, record review, staff, and Nurse Practitioner (NP) interviews, the facility failed to assess, monitor, document progress, and provide treatment for an open wound (skin tear) on the top of Resident #11's right foot for 1 of 5 residents reviewed for skin concerns. Weekly skin checks did not include the existence of a dressing to the right foot from the end of November 2023 through the end of February 2024. Observation on 2/27/24 revealed a dressing dated 11/17 on the top of the right foot. Once the dressing was removed from the top of the right foot, a wound with a dark hard perimeter and a soft yellow center was noted. Findings included: Resident #11 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's dementia, colostomy, and peripheral vascular disease. Review of Resident #11's care plan indicated a 4/27/23 focus of at risk for pressure ulcer development with interventions which indicated to report to the nurse immediately redness, open areas, or irritation on…

  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

“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

$126,586 in federal fines across 4 penalties.

• $69,518 — penalty dated 2024-07-26
• $45,429 — penalty dated 2024-02-29
• $4,196 — penalty dated 2023-09-15
• $7,443 — penalty dated 2023-09-15

Dates are the dates CMS records the penalty, not the date of the conduct behind it. CMS publishes penalties on a rolling window, so this is what is currently on the public file — not the home’s lifetime history, and an older fine may attach to a problem that has since been corrected. The amounts are as imposed: the CMS file does not record whether a penalty was appealed, reduced, or paid, so we don’t say. Ask the home what each one was for and what changed since.

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 13 rows in the source record cover these 10 parties — each is shown once here with every role it holds. Nothing is omitted.

2 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.

This home reported $2.3M paid to related parties — landlords or management companies under common ownership — equal to about 21% 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.

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