Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Liberty Health And Wellness during CMS and state inspections, most recent first.
A resident with cognitive decline and a history of brain cancer left the facility unsupervised after signing out to smoke. Despite being identified as an elopement risk, the facility failed to implement effective interventions or monitor the resident adequately. The resident was later found at a hospital 18 miles away, indicating a failure to follow elopement procedures.
A facility failed to maintain infection control standards during care for three residents. Staff did not perform hand hygiene with glove changes, failed to wear gowns for residents on Enhanced Barrier Precautions, and placed dirty linens on the floor. Observations showed staff not adhering to infection control policies, and interviews revealed gaps in training and awareness.
Facility staff failed to provide complete perineal care for two residents, leading to a deficiency. One resident with paraplegia and bladder incontinence did not receive proper cleaning as staff used a wet hand towel instead of wipes and did not separate perineal folds. Another resident, dependent on staff for personal care, was cleaned with the same wipe for multiple swipes, and staff did not separate perineal folds. Interviews with LPN and DON confirmed the staff did not meet expected care standards.
A resident with an indwelling urinary catheter received improper care, as a CNA was observed cleaning the catheter incorrectly and placing the drainage bag on the mattress, contrary to facility policy. Interviews with staff confirmed the failure to follow proper procedures, leading to a deficiency in preventing UTIs.
Two residents in a LTC facility suffered injuries due to inadequate supervision and improper handling during transfers and physical therapy. One resident, identified as a fall risk, was left unsupervised during therapy and sustained fractures after a fall. Another resident was transferred without a gait belt, resulting in an ankle fracture. The facility's failure to adhere to policies on safe handling and supervision contributed to these incidents.
A resident did not receive the physician-ordered medication, Protonix, for three days due to unavailability in the medication cart. Despite the pharmacy delivering a 30-day supply, the medication was not administered as required, leading to resident frustration and highlighting a lapse in the facility's medication management process.
The facility failed to maintain resident dignity and privacy, as evidenced by incidents where a resident's soiled sheets were not changed, staff entered a room without knocking, and two residents did not receive their meals simultaneously. These actions affected the residents' dignity and privacy, as confirmed by staff interviews.
The facility failed to ensure safe self-administration of medications for two residents. One resident, who is cognitively intact, was found with eye drops at the bedside without a physician's order or care plan reflecting self-administration. Another resident, dependent on staff for various activities, had medications at the bedside without proper orders or care plan documentation. Staff interviews revealed a lack of awareness and documentation regarding self-administration, contrary to facility policy.
The facility failed to address and communicate resolutions to concerns raised by the resident council, as reported by nine out of ten residents. Issues such as door code changes, smoke break arrangements, and CNA conduct were documented, but residents felt there was no effective follow-up or resolution. Interviews revealed that grievances were supposed to be addressed by relevant departments, but residents often received no substantial feedback.
The facility failed to maintain a safe and homelike environment, with observations revealing dirty linens, unpainted patches, chipping paint, and dead bugs in light fixtures. Staff interviews indicated lapses in responsibilities, with a CNA not noticing stained sheets and the maintenance supervisor aware of needed repairs but not addressing them promptly.
The facility failed to provide meaningful activities for several residents, including those with cognitive impairments and physical disabilities. One resident expressed dissatisfaction with the lack of preferred activities like sudoku puzzles, while another, who is legally blind, struggled to participate due to inadequate support and unsuitable activity options. A third resident reported boredom and frustration, as their preferred activities were not offered. Additionally, a resident's activity assessment was not completed, indicating a lack of personalized activity planning.
The facility failed to ensure call lights were within reach for three residents, leading to potential safety hazards. One resident with upper extremity impairments was found with the call light on the floor, out of reach, despite being dependent on staff for mobility. Another resident with severe cognitive impairment also had the call light under the bed, contrary to care plan requirements. A third resident, affected by a stroke, was similarly unable to reach the call light. Staff interviews revealed a lack of adherence to the policy of ensuring call light accessibility.
The facility failed to provide fresh water at residents' bedsides and did not date the Styrofoam cups used, affecting three residents with various medical conditions. Observations and interviews revealed that staff did not consistently provide fresh ice water every shift, and the cups were not dated, leading to uncertainty about their usage duration. Staff interviews confirmed the inconsistency in following procedures for hydration care.
The facility failed to provide proper respiratory care by not cleaning oxygen concentrator filters for four residents, leading to dust accumulation. Residents on oxygen therapy for conditions like asthma and COPD were affected. Staff interviews revealed a lack of knowledge and responsibility for cleaning the filters, which were expected to be maintained weekly. The DON and Administrator acknowledged the deficiency.
A long-term care facility reported a 23.08% medication error rate, affecting four residents. Errors included improper administration of Glycolax, Lidocaine patches, Albuterol inhalers, Advair Diskus, Artificial Tears, and Fluticasone Propionate nasal spray. Observations revealed discrepancies between physician orders and actual practices, with staff failing to follow manufacturer guidelines and leaving medications at the bedside.
The facility failed to securely store and properly label medications, with instances of medications left unattended at a resident's bedside, expired medications not discarded, and improperly labeled medications. Staff interviews revealed a lack of clarity on procedures for checking and removing expired medications, and the Director of Nursing's audits did not prevent these deficiencies.
The facility failed to meet food safety standards, with staff not wearing hairnets and multiple sanitation issues in the kitchen, including uncovered light fixtures and mold-like substances. Food trays were transported without proper covers, exposing them to contaminants. The dietary manager and administrator acknowledged these issues, highlighting a need for improved compliance with safety protocols.
The facility failed to accommodate the needs of a paraplegic resident by not providing an escort for physician appointments and not honoring their preference for paper chux. Additionally, a visually impaired resident was not provided with appropriate activities, as they reported difficulty participating due to blindness and arthritis. Staff interviews revealed a lack of clarity regarding the scheduling of escorts and provision of activities for residents with specific needs.
The facility failed to provide adequate hygiene care for several residents, with issues in perineal care and shower frequency. Two residents did not receive complete perineal care, and three residents missed multiple shower opportunities. Staff acknowledged these deficiencies, and residents expressed dissatisfaction with their hygiene care.
A resident with terminal cancer reported that a former Social Services Director sold their possessions, including a 2011 Mercedes, without providing the proceeds. The resident, who was cognitively intact, expressed significant emotional distress over the theft. The facility's investigation confirmed the misappropriation, and the police were notified. The facility's policies on protecting resident property were not effectively enforced.
A resident with multiple diagnoses had medications unsafely stored at their bedside, contrary to the facility's policy. The resident self-administered these medications without staff assistance, and staff confirmed that medications should not be kept at the bedside due to potential hazards.
A facility failed to provide medically related social services for a resident with terminal cancer, who experienced significant distress due to a stolen car and lack of support. The resident's care plan was not followed, and necessary assessments and interventions were not completed, leading to increased anxiety and depression.
The facility failed to maintain a complete health record for a resident with pressure ulcers by not documenting wound treatments on the TAR on multiple occasions. Interviews revealed that treatments were sometimes performed but not documented, and the resident's schedule affected the timing of treatments. The DON and Administrator expected documentation after treatment, but the DON was unaware of the lapses.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision and identify an elopement risk for a resident who had been deemed incapacitated. The resident, who had a history of brain cancer, cognitive decline, and was at low risk for wandering, left the facility unsupervised after informing staff he was going out to smoke. Despite being identified as an elopement risk with impaired safety awareness, the facility did not implement effective interventions to prevent the resident from leaving the premises. The resident had previously displayed behaviors indicating a desire to leave the facility, such as attempting to exit through various doors and expressing a wish to go to the casino. The facility's staff, including the DON and SSD, were aware of the resident's cognitive decline and the need for supervision while smoking. However, the facility did not complete a smoking assessment or update the resident's care plan with new interventions after the resident's attempts to leave the facility. On the day of the incident, the resident signed out on the smoking log and left the facility. The staff failed to monitor the resident effectively, and the resident was later found at a hospital 18 miles away. The facility did not follow its policy and procedure for elopements, as evidenced by the lack of a police report and the failure to notify the appropriate parties promptly. The resident's DPOA was under the impression that the resident would not leave the property unsupervised, highlighting a communication breakdown between the facility and the resident's representative.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain infection control standards during the provision of care to three residents. Staff did not perform hand hygiene with glove changes while performing perineal care for two residents and did not change gloves when providing urinary catheter care for another resident, as per facility policy. Additionally, staff failed to wear gowns while providing catheter care and perineal care for residents on Enhanced Barrier Precautions (EBP) and while emptying urinary catheter drainage bags. Dirty linens and used incontinence briefs were placed directly on the floor instead of in bags, contrary to facility policy. Resident #2, who had paraplegia and an indwelling urinary catheter, was observed receiving perineal care without staff performing hand hygiene between glove changes. Staff also failed to wear protective gowns and placed dirty linens on the floor. Resident #3, who had a chronic wound and required assistance with personal care, was observed receiving perineal care without staff performing hand hygiene or wearing protective gowns. Staff used contaminated wipes and placed dirty linens on the floor. Resident #4, who had an indwelling urinary catheter, received catheter care without staff performing hand hygiene or wearing protective gowns, and dirty gloves were not changed appropriately. Interviews with staff, including CNAs, LPNs, the Director of Nursing, and the Administrator, revealed a lack of adherence to infection control policies and procedures. Staff acknowledged the need for hand hygiene, proper glove use, and the use of protective gowns, but these practices were not consistently followed. The Director of Nursing and the Administrator expressed expectations for compliance with EBP and infection control protocols, but gaps in training and awareness were evident among staff members.
Deficient Perineal Care for Two Residents
Penalty
Summary
The facility staff failed to provide complete perineal care for two dependent residents, leading to a deficiency in care. Resident #2, who had a BIMS score of 15 indicating no cognitive deficit, was diagnosed with paraplegia, bladder incontinence, and anxiety, and was dependent on staff for personal hygiene and urinary catheter care. During an observation, CNA A and NA A did not perform hand hygiene, used a wet hand towel instead of wipes, and failed to separate the resident's perineal folds while cleaning. They also used a scrubbing motion and wiped back to front, contrary to the facility's policy. Resident #3, with a BIMS score of 13 indicating minimal cognitive deficit, required assistance with personal care and was incontinent of bowel and bladder. During an observation, CNA B and CNA C used the same wipe for multiple swipes and did not separate the resident's perineal folds. CNA B wiped back to front, which was against the expected procedure. Both CNAs acknowledged their failure to follow the correct perineal care procedure during interviews. Interviews with LPN C and the DON revealed that the staff did not meet the expected standards for perineal care. They confirmed that the staff should have used a clean wipe for each swipe, wiped front to back, and separated the perineal folds. The DON reiterated the importance of following the correct procedure to ensure proper hygiene and prevent infection.
Improper Catheter Care Leads to Deficiency in UTI Prevention
Penalty
Summary
The facility failed to provide proper urinary catheter care for a resident, leading to a deficiency in preventing urinary tract infections (UTIs). The resident, who had a BIMS score indicating little cognitive deficit, was diagnosed with a UTI, urine retention, and required assistance with personal care. The resident had an indwelling urinary catheter and needed help with dressing, using the toilet, and bed mobility. The facility's policy required catheter care to be performed by wiping from the body outward and ensuring the urinary drainage bag was below the bladder level to prevent backflow. During an observation, a CNA was seen improperly cleaning the resident's catheter by rubbing back and forth instead of wiping in one direction. The CNA also placed the urinary drainage bag on the resident's mattress, which is against the facility's policy. Interviews with the CNA, an LPN, the DON, and the Administrator confirmed that the staff did not follow the correct procedures for catheter care, as they were expected to swipe once from top to bottom and keep the drainage bag below the bladder level. This improper handling of catheter care was identified as a deficiency affecting the resident's care.
Inadequate Supervision and Handling During Transfers and Therapy
Penalty
Summary
The facility failed to provide adequate supervision and safe handling during physical therapy sessions, resulting in injuries to two residents. Resident #4, who had no cognitive impairment and required substantial assistance for mobility, was left unsupervised while performing standing exercises at the parallel bars. Despite being identified as a fall risk, the resident was not closely monitored, and staff were not in a position to prevent the fall. The resident fell, sustaining a displaced hip fracture and a tibia fracture, which required hospitalization. The care plan for Resident #4 did not adequately address the resident's mobility needs, fall risk, or the necessity for close supervision during therapy. In another incident, Resident #6, who had cognitive skills intact but required substantial assistance for transfers, was improperly transferred from bed to a wheelchair without the use of a gait belt, contrary to the facility's policy. During the transfer, the resident was lowered to the floor, resulting in an acute medial malleolar fracture. The staff involved did not follow the proper protocol for using a gait belt, and the resident's care plan did not adequately address the risk of falls or the need for specific transfer assistance. Both incidents highlight a lack of adherence to the facility's policies on safe resident handling and supervision, particularly during transfers and physical therapy sessions. The failure to ensure proper supervision and use of assistive devices like gait belts contributed to the injuries sustained by the residents. The facility's policies were not effectively implemented, and staff were not adequately informed or attentive to the residents' needs during these critical activities.
Medication Unavailability for Resident
Penalty
Summary
The facility failed to ensure that a physician-ordered medication, Protonix, was available and administered to a resident for three consecutive days. The resident, who was cognitively intact and had multiple diagnoses including cancer, heart disease, high blood pressure, stroke, and lung disease, did not receive the medication on 12/24/24, 12/25/24, and 12/26/24 as per the Medication Administration Record. The facility's Medication Administration Policy requires staff to keep the medication cart stocked with adequate supplies, but this was not adhered to in this instance. On 12/26/24, a Certified Medical Technician (CMT) was observed searching for the medication but could not find it in the cart. The resident expressed frustration about having to track down a nurse to receive the medication. Interviews with staff revealed that the pharmacy had delivered the medication on 12/17/24, but it was not available on the cart when needed. The Director of Nursing confirmed that the medication had been requested again from the pharmacy on 12/26/24. The pharmacy later confirmed that a 30-day supply had been delivered and signed for by staff, indicating a lapse in the facility's medication management process.
Deficiencies in Resident Dignity and Privacy
Penalty
Summary
The facility failed to maintain resident dignity and privacy, as evidenced by several incidents involving different residents. One resident, who was incontinent of urine and bowel, reported that the night shift nurse did not change their soiled bed sheets on two consecutive nights, leaving them embarrassed and angry. The resident was forced to either sleep on the wet sheets or endure the smell of urine. Interviews with staff confirmed that the night shift was expected to change soiled sheets, but this was not done for the resident in question. Another incident involved a resident whose privacy was compromised when staff entered their room without knocking, despite a 'Do Not Disturb' sign on the door. The resident expressed a desire for staff to knock and announce themselves before entering. The dietary manager admitted to not knocking before entering the resident's room, and the Director of Nursing stated that all staff were expected to knock and announce themselves before entering a resident's room. Additionally, two residents in the dining room did not receive their meals at the same time as others sharing their table, further indicating a lack of attention to resident dignity.
Failure to Ensure Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that staff obtained physicians' orders and assessed residents for safe self-administration of medications to be kept at the bedside for two residents. Resident #41, who is cognitively intact and independent with most activities of daily living but requires supervision for walking, was found with an unexpired bottle of eye drops at the bedside without a physician's order to self-administer or keep the medication at the bedside. The resident's care plan did not reflect the ability to self-administer medications or keep them at the bedside. Similarly, Resident #76, who is cognitively intact but dependent on staff for various activities, was found with a bottle of Artificial Tears Ophthalmic Solution and a tube of Zinc Oxide on the bedside table. There was no physician's order for the resident to self-administer these medications or keep them at the bedside. The care plan did not reflect the resident's ability to self-administer medications. Interviews with facility staff, including a Certified Medication Tech and an LPN, revealed a lack of awareness and documentation regarding residents' self-administration of medications, contrary to the facility's policy.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to adequately address and communicate the concerns and recommendations of the resident council members, as reported by nine out of ten residents who attended a group meeting. The residents expressed that while their grievances were noted during council meetings, there was no effective follow-up or resolution communicated to them. This lack of communication and resolution was evident in the resident council minutes, which did not indicate whether the issues raised were resolved or if the residents still considered them to be ongoing problems. The resident council minutes from meetings held on two separate occasions highlighted several issues, including door code changes, smoke break arrangements, courtyard maintenance, and concerns about laundry, housekeeping, and CNA conduct. Despite these issues being documented, the residents reported that during follow-up meetings, staff only read the old business without providing updates on resolutions or addressing whether the residents still perceived these issues as unresolved. Interviews with the Activity Director and the Director of Nursing revealed that grievances voiced during meetings were supposed to be written up and addressed by the appropriate departments. However, the residents felt that the process was ineffective, as they were often told to fill out a grievance form without receiving any substantial feedback or resolution. This lack of effective communication and follow-up on grievances contributed to the deficiency identified in the facility's handling of resident council concerns.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to uphold the residents' right to a safe, clean, comfortable, and homelike environment. Observations over several days revealed multiple deficiencies, including dirty and stained bed linens in several rooms, unpainted patches on walls, chipping paint on ceilings, dead bugs in light fixtures, and unpatched holes in walls and ceilings. The facility's policy mandates maintaining a sanitary and orderly environment, but these observations indicate a failure to adhere to these standards. Interviews with staff, including a CNA, the Director of Nursing, and the housekeeping and maintenance supervisors, highlighted lapses in responsibilities. The CNA admitted to not noticing the stained sheets, despite being responsible for changing them. The Director of Nursing expected CNAs to ensure clean linens, while the housekeeping supervisor mentioned a rotating cleaning schedule that was not effectively addressing the issues. The maintenance supervisor acknowledged awareness of the need for repairs and painting, indicating a lack of timely action to address these environmental deficiencies.
Failure to Provide Meaningful Activities for Residents
Penalty
Summary
The facility failed to provide meaningful activities for five residents, as observed through interviews and record reviews. Resident #55, with moderately impaired cognition and various health conditions, expressed dissatisfaction with the activities offered, stating a preference for sudoku puzzles, which were not provided. The resident's activity evaluation indicated interests in cooking, religious activities, and music, but these preferences were not reflected in the activities offered. Resident #419, who is legally blind and has multiple health issues, reported difficulties in participating in activities due to blindness and arthritis. The resident was unable to operate the television and had not been offered suitable alternatives, such as audio books, despite expressing interest in educational programs and music. The resident's participation record showed repetitive activities that did not align with their preferences or abilities. Resident #95, who is cognitively intact but has a seizure disorder and depression, expressed boredom and frustration with the lack of engaging activities. Despite having a detailed list of preferred activities, such as arts and crafts and social events, the resident reported that these preferences were not being met. Additionally, Resident #76's records showed no completed activity assessment, and the Activities Supervisor admitted that assessments were not consistently conducted, leading to a lack of personalized activity planning.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards for three residents, as their call lights were not within reach. Resident #6, who had no cognitive impairment but had upper extremity impairments and was dependent on staff for bed mobility and toileting, was observed on two occasions with the call light on the floor, out of reach. Despite being in bed and calling for assistance, staff failed to place the call light within reach during their interactions. Resident #23, with severe cognitive impairment and upper extremity impairments, was also found with the call light under the bed and out of reach. This resident was dependent on staff for all activities of daily living and was at risk for falls. The care plan specifically required staff to ensure the call light was accessible, yet observations showed this was not adhered to. Similarly, Resident #75, who had no cognitive impairment but had impairments due to a stroke, was observed with the call light on the floor and out of reach. Interviews with staff, including CNAs and the LPN, revealed a lack of awareness and adherence to the policy of ensuring call lights are within reach. Additionally, a call light cord in a restroom was found to be shortened, further indicating a failure to maintain accessible call lights for residents.
Failure to Provide Fresh Water and Date Cups
Penalty
Summary
The facility failed to ensure that residents had fresh water at their bedside that was easily accessible and failed to date the Styrofoam cups used for fresh water. This deficiency affected three residents, each of whom had intact cognitive skills and required assistance with eating. The residents had various diagnoses, including COPD, CHF, diabetes mellitus, anxiety, depression, and unsteadiness on feet. Observations and interviews revealed that the staff did not consistently provide fresh ice water every shift, and the Styrofoam cups were not dated, making it difficult to determine how long they had been in use. Interviews with staff, including an LPN, CNAs, and the DON, confirmed that fresh ice water should be provided every shift and that the Styrofoam cups should be dated and changed regularly. However, there was inconsistency in the staff's understanding and execution of these procedures. The residents expressed a desire for fresh ice water every shift, and one resident noted that the staff only provided fresh water because the State was in the building. The lack of adherence to the facility's policy for assisted nutrition and hydration contributed to the deficiency.
Failure to Clean Oxygen Concentrator Filters
Penalty
Summary
The facility failed to ensure proper respiratory care for four residents by not effectively cleaning the oxygen concentrator filters. The facility's Oxygen Administration Policy did not address the cleaning of concentrator filters, leading to neglect in maintaining these essential components. Observations revealed that the filters on the oxygen concentrators for the residents were thick with built-up dust and gray lint, indicating a lack of regular cleaning. Resident #74, who had no cognitive impairment and required supervision for activities of daily living (ADLs), was observed with a dusty oxygen concentrator filter. The resident was on oxygen therapy due to diagnoses including cancer, asthma, and respiratory failure. Similarly, Resident #103, also without cognitive impairment and requiring supervision for ADLs, had a concentrator filter covered in dust. This resident was on oxygen therapy for asthma, respiratory failure, and anxiety. Interviews with staff, including CNAs and an LPN, revealed a lack of knowledge and responsibility regarding the cleaning of oxygen concentrator filters. The CNAs were expected to clean the filters weekly, but some staff members were unaware of how to perform this task. The Director of Nursing and the Administrator acknowledged that the filters should be cleaned at least monthly and expressed that they should not be caked with dust and dirt.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 23.08% error rate. This affected four residents, with errors observed in the administration of medications such as Glycolax, Pulmicort, Lidocaine patches, Albuterol inhalers, Advair Diskus, Artificial Tears, and Fluticasone Propionate nasal spray. The errors were identified through observations, interviews, and record reviews, highlighting discrepancies between physician orders and actual administration practices. For Resident #28, the errors included improper administration of Glycolax, failure to change a Lidocaine patch since 10/20/24, and incorrect use of an Albuterol inhaler without a documented physician's order. The resident experienced severe back/hip pain, and the CMT left the Glycolax medication at the bedside, which was not consumed by the resident. The CMT also admitted to being unfamiliar with the Albuterol inhaler and failed to administer the correct dosage. Other residents experienced similar issues. Resident #8 did not rinse their mouth after receiving Advair Diskus, contrary to manufacturer guidelines. Resident #11 did not receive proper pressure application after receiving Artificial Tears, and Resident #42's Fluticasone Propionate nasal spray was administered without closing one nostril as required. The Director of Nursing confirmed that medications should be administered as ordered and according to manufacturer guidelines.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure medications were stored securely and properly labeled, leading to several deficiencies. Medications were found left unattended at a resident's bedside, including a bottle of Zinc Oxide paste, Antifungal Ointment, hair and skin spray cleanser, Genteal Tears liquid drops, and an unlabeled bottle containing an unknown green fluid. These items were not labeled with the resident's name, and the resident was not present in the room at the time of observation. The facility's policy requires that medications not authorized for bedside storage be reported and returned to the charge nurse, but this was not adhered to. Additionally, the facility did not discard expired medications, affecting two residents and house stock items. Expired medications found included a bottle of Eliquis, Losartan, and Donepezil for one resident, and Carbamazepine for another. House stock items such as lubricating eye drops and Insta-glucose were also expired. The facility's policy mandates that expired medications be removed and destroyed, but this was not followed, as confirmed by interviews with staff who were unsure of the procedures for checking and removing expired medications. Furthermore, medications were not properly labeled, as observed with an opened tube of Mupirocin ointment with a faded label. The facility's policy requires that all medications be clearly labeled, but this was not the case. Interviews with staff revealed a lack of clarity on who was responsible for checking medication carts and ensuring labels were legible. The Director of Nursing was noted to perform audits, but expired and improperly labeled medications were still present, indicating a lapse in adherence to the facility's medication storage and labeling policies.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards of food service safety, as observed during a survey. Staff did not comply with hairnet requirements, allowing two visitors to walk through the kitchen without hairnets and a dietary aide working without a hairnet on multiple occasions. Additionally, the kitchen had several sanitation issues, including uncovered light fixtures, mold-like substances on water-damaged documents, old food debris on refrigerator racks, and congealed liquid in a machine drip tray. The ceiling paint was chipping, and dust was hanging from the fire suppression system, indicating a lack of cleanliness and maintenance. Furthermore, food trays were transported through the facility without proper covers, exposing them to environmental contaminants. The facility's policy required food containers to be covered to retain heat and prevent contamination, but the staff believed that individual covers and plastic wrap sufficed. The dietary manager and dietician acknowledged the need for light fixture covers and stated that deep cleaning was performed twice a month. The administrator confirmed the expectation for meals to be served promptly and covered, and for hairnets to be worn by anyone in the kitchen.
Failure to Accommodate Resident Needs and Preferences
Penalty
Summary
The facility failed to accommodate the needs and preferences of Resident #24 by not providing an escort for physician appointments and not honoring the resident's preference for paper chux. Resident #24, who is paraplegic and has multiple medical conditions including anxiety and chronic pain, expressed concerns about attending appointments alone due to social anxiety and the potential need for assistance with his colostomy and drainage bags. Despite the resident's preference and the wound physician's recommendation for paper chux and an escort, the facility did not have a physician's order for these accommodations, and staff were unaware of the resident's preference for paper chux. Additionally, the facility did not provide appropriate activities for Resident #419, who is visually impaired. Although the resident expressed interest in various activities such as reading, writing, and music, they reported not participating in activities due to blindness and difficulty operating the television. The resident also mentioned not being offered activities other than audio books and not attending puzzle activities due to arthritis and blindness. The facility's activity records showed limited participation, and staff failed to assist the resident in accessing desired activities or turning on the television. Interviews with facility staff revealed a lack of clarity and communication regarding the scheduling of escorts for appointments and the provision of activities for residents with specific needs. The Social Services Director and LPNs were unsure about the process for determining the need for escorts, and the Director of Nursing stated that no residents had physician's orders for escorts. The Administrator expected staff to assist residents with blindness in participating in activities, but this was not consistently documented or executed.
Deficiencies in Resident Hygiene Care
Penalty
Summary
The facility failed to ensure that dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene. This deficiency affected five residents, with specific issues in perineal care and shower frequency. For two residents, staff did not provide complete perineal care, failing to clean all necessary areas, including the perineal folds and urethral opening, as required by the facility's policy. This was observed during interactions with the residents, and staff admitted to not following the proper procedures. Additionally, three residents did not receive showers at least twice a week as required. The facility's records showed that these residents missed several shower opportunities over multiple months. One resident expressed feeling better after being cleaned, indicating the importance of regular hygiene care. Another resident frequently refused showers due to feeling unsafe, and there was an incident where a staff member inadvertently caused distress by entering the shower area. Interviews with staff, including CNAs and the DON, confirmed the issues with shower frequency and perineal care. Staff acknowledged the residents' complaints about not receiving showers as per their preferences. The facility's policy mandates that residents should receive the necessary services to maintain good personal hygiene, but the observations and interviews revealed a failure to adhere to these standards.
Misappropriation of Resident Property by Former Social Services Director
Penalty
Summary
The facility failed to protect a resident from misappropriation of property, specifically involving a former Social Services Director (PSSD) who was reported to have sold the resident's possessions, including a 2011 Mercedes, without providing the resident with the money received from the sales. The resident, who had terminal cancer, reported being devastated by the theft, as the car was a significant personal achievement. The resident's cognitive status was intact, as indicated by a BIMS score of 15, and they had expressed the importance of having a place to lock their belongings to keep them safe. The deficiency was identified when the resident reported to the Admissions Director that the PSSD had been helping them sell their car and personal belongings, but the items were now missing, and the resident had not received any money. The facility's investigation revealed that the PSSD had picked up the resident's car from the hospital, sold it, and paid off the car loan using their personal bank account. However, the resident did not receive any proceeds from the sale. The PSSD was terminated from their position for unrelated reasons, and the police were notified of the incident. Interviews with various staff members and the resident confirmed the misappropriation of property. The resident expressed significant emotional distress and frustration over the situation, feeling that the facility had not provided a resolution or kept them updated on the investigation. The resident's behavior and mood were notably affected by the incident, leading to outbursts and increased seclusion. The facility's policies on abuse, neglect, and exploitation, as well as the protection of resident personal belongings, were not effectively implemented or enforced in this case, resulting in the misappropriation of the resident's property.
Unsafe Medication Storage at Resident's Bedside
Penalty
Summary
The facility failed to ensure the environment for one resident remained free of accident hazards, specifically by allowing medications to be unsafely stored at the resident's bedside. The facility's Medication Storage policy mandates that all medications be stored in locked compartments and only accessible to authorized personnel. However, observations revealed that Resident #58 had an inhaler and sulfadiazine cream at the bedside, which the resident had been self-administering without staff assistance. Additionally, the resident had antifungal powder and hydrocortisone cream at the bedside without a physician's order for these medications. Interviews with staff confirmed that medications should not be kept at the bedside due to the risk of other residents potentially ingesting them. Resident #58, who had diagnoses including encephalopathy, bipolar disorder, diabetes, chronic obstructive pulmonary disease, and osteoarthritis, was admitted to the facility on 08/18/2022. The resident had a BIMS score of 15, indicating intact cognition, and had a care plan that did not address self-administration of medications or safe storage of medications in the resident's room. Despite the facility's policy and staff assertions that medications should not be kept at the bedside, the resident had multiple medications accessible, posing a potential hazard. The Director of Nursing confirmed that medications should not be kept at the bedside and noted that the resident was an online shopper who bought medication online.
Failure to Provide Medically Related Social Services
Penalty
Summary
The facility failed to provide medically related social services for a resident who had recently been diagnosed with terminal cancer, lost their job, and became homeless due to their health condition. The resident, who had a history of trauma, showed signs of mental and psychosocial distress, including anxiousness and depression. The resident also reported that a previous social worker had stolen their car, which added to their distress. Despite these significant issues, the facility did not provide adequate follow-up or support to address the resident's needs. The resident's care plan indicated a need for psychiatric evaluation and referral to social services, but there was no documentation of a trauma-informed care assessment or follow-up after the incident with the stolen car. The Social Services Director (SSD) acknowledged that they had not completed the necessary assessments or provided the required support. The resident expressed feelings of being neglected and unsupported by the facility staff, who did not check in on them or offer updates regarding the stolen car. Interviews with the resident and staff revealed that the resident's behavior had changed significantly due to the distress caused by the stolen car and their terminal diagnosis. The resident had outbursts and expressed feelings of devastation and extreme stress. Despite these clear signs of distress, the facility did not take appropriate steps to address the resident's psychological and social needs, failing to provide the necessary support and interventions as required by their care plan and facility policies.
Failure to Document Wound Treatments
Penalty
Summary
The facility failed to maintain a complete health record for one resident reviewed for pressure ulcers. Specifically, the staff did not document wound treatments on the Treatment Administration Record (TAR) for Resident #35 on multiple occasions across January, February, and March 2024. The resident had diagnoses including type 2 diabetes mellitus, chronic combined congestive heart failure, end-stage renal disease, and dependence on renal dialysis. The resident's care plan included instructions for wound treatment, but the TAR revealed missing documentation for several dates when treatments were supposed to be administered. Interviews with nursing staff indicated that treatments were sometimes performed but not documented, and in some cases, the resident's preferences or schedule (such as dialysis) affected the timing of treatments. The Director of Nursing (DON) and the Administrator both stated that they expected all treatments to be documented after completion. However, the DON was not aware that staff had failed to document treatments for Resident #35 on some days. The failure to document wound treatments as required by the facility's policy and physician orders led to the deficiency identified in the report.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Liberty
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Norterre | 0.1 mi | ★★★★★ | 1 | 0 |
| Avalon View Health And Wellness | 2.3 mi | ★★★★★ | 10 | 0 |
| Pleasant Valley Manor Care Center | 5.1 mi | ★★★★★ | 16 | 2 |
| Linden Woods Village | 7.4 mi | ★★★★★ | 0 | 0 |
| Ignite Medical Resort Kansas City, Llc | 8.1 mi | ★★★★★ | 11 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.