Average — CMS composite of the measures below.
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 Norterre during CMS and state inspections, most recent first.
A resident with severe cognitive and physical impairments, fully dependent on staff, was found in a room with a portable electric heater running as a temporary solution for a broken heating system. The heater was vented to the outside and left unattended, with no additional staff checks or fire risk precautions in place. Staff interviews revealed a lack of clear oversight or policy regarding the use of such equipment, and the facility could not provide a policy on accident hazards when requested.
The facility failed to refund personal funds within thirty days of discharge for three residents, as required by policy. The Business Office Manager cited delays in the corporate process for issuing refund checks, affecting the timely conveyance of funds.
The facility failed to develop comprehensive care plans for three residents by not addressing side rail use. One resident with moderate cognitive impairment used side rails for mobility due to a stroke, but this was not reflected in their care plan. Another resident, severely cognitively impaired, also used side rails without care plan documentation, despite a physician's order. A third resident, dependent for all mobility, had side rails installed without a care plan or physician's order. Staff interviews revealed inconsistencies in care plan documentation and responsibilities.
An LPN at the facility prepared medications in advance and stored them in the medication cart, contrary to the facility's policy requiring immediate administration. This practice was observed for multiple residents, including those with conditions like high blood pressure and dementia. The Director of Nursing and Administrator confirmed this was against expectations, emphasizing the need for immediate medication administration.
The facility failed to provide necessary personal hygiene care for residents, including regular perineal care and showers. Several residents with severe cognitive impairments were not checked for incontinence every two hours, and a resident dependent on a wheelchair missed multiple scheduled showers due to scheduling conflicts and staff being behind on care.
The facility failed to provide an ongoing program to support residents in their choice of activities, affecting six residents. Observations and interviews revealed that residents were not offered convenient access to activities, informed when activities would occur, or encouraged to attend. Several residents reported a lack of engagement and awareness of available activities, and staff interviews highlighted a lack of coordination and communication regarding activities.
The facility failed to recognize and address significant weight loss in two residents, leading to deficiencies in care. One resident lost 9.44% of their weight in less than a month, with no documentation or physician notification. Another resident experienced a 7.62% weight loss, also without proper documentation or action. Staff interviews revealed communication and documentation issues, with the Registered Dietitian not being informed of significant weight loss and CNAs not reviewing care documents. The DON suggested a possible scale error but had not verified it.
A facility failed to assess and manage bed rail use for three residents, leading to deficiencies. One resident with cognitive impairment used side rails without a risk assessment or physician's order. Another resident had side rails installed before obtaining a physician's order, and a third resident had side rails without documented consent or evaluation. The facility's process lacked coordination and adherence to required procedures.
A medication error rate of 28% occurred when an LPN prepared and another LPN administered medications for a resident with multiple health conditions, contrary to facility policy. The error involved preparing medications in advance and not adhering to the guideline that only the preparer should administer them.
The facility failed to follow professional standards for food service safety, with numerous undated and improperly stored food items found during a survey. This included expired products, improperly sealed containers, and items stored on the floor, potentially exposing residents to foodborne illnesses. Interviews revealed discrepancies between facility policy and actual practices.
The facility failed to provide sufficient dining space, resulting in crowded tables and some residents being turned away. Observations showed inadequate seating and setup in dining areas, affecting residents' dining experiences. Some residents had to eat in their rooms due to lack of space, despite preferring to dine with others.
The facility failed to employ a qualified activity professional to oversee its activity program. The current Activity Director has not completed an approved training program and has not received formal job-specific training. Despite attempts to participate in scheduled training calls, the Activity Director was unable to receive guidance. The Administrator acknowledged the deficiency and is in the process of enrolling the Activity Director in a training program.
Portable Heater Used in Resident Room Creates Accident Hazard
Penalty
Summary
A deficiency occurred when the facility failed to maintain a resident's environment free from accident hazards by using a portable electric heater in a resident's room. The resident involved had severe cognitive impairment, impairment in both upper and lower extremities, was dependent on staff for all activities of daily living, and had diagnoses including respiratory failure and anxiety. The resident's care plan indicated a self-care deficit and total dependence on staff. During observation, a portable heater was found running in the resident's room, set to 87 degrees Fahrenheit, with a hose vented to the window and secured by tape, and no staff present in the room. The facility was unable to provide a policy regarding safe environment or accident hazards when requested. Interviews with staff revealed a lack of awareness and oversight regarding the use of the portable heater. An LPN was unsure how long the heater had been in use and had not been instructed to perform additional checks for fire risk. The Maintenance Director stated that the heater was installed as a temporary measure while waiting for repairs to the room's heating system, but acknowledged uncertainty about when it was placed and recognized it should not have been used. The Administrator confirmed awareness of the heater's use as a temporary solution and stated that portable heaters should not be used in resident rooms.
Delayed Refund of Resident Funds Post-Discharge
Penalty
Summary
The facility failed to provide personal conveyance of personal funds within thirty days of discharge for three residents. Resident #205 was discharged with a balance of $3,250.00, Resident #206 with a balance of $6,490.00, and Resident #207 with a balance of $325.00. The facility's policy required that if a resident's personal funds were deposited, the facility should refund the account balance within thirty days and provide a full accounting of these funds. However, the Business Office Manager (BOM) indicated that the process was delayed due to the need to request a new vendor account from the corporate office before issuing a refund request. This process involved submitting a vendor request, waiting for corporate to create a new account, and then submitting a refund request, which was dependent on the speed of the referral process. During interviews, the BOM explained that refunds were paid out of the corporate office and that the facility had thirty days to return funds to the resident or their responsible party upon discharge. However, the BOM was still waiting on refund checks from the corporate office for Residents #205 and #206. For Resident #207, the refund request was delayed due to the responsible party's request to wait in case additional respite was used. The Administrator confirmed the expectation that personal funds should be conveyed within thirty days of discharge.
Failure to Address Side Rail Use in Care Plans
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for three residents by not addressing the use of side rails. Resident #10, who had moderate cognitive impairment and was dependent on a wheelchair, used side rails to assist with mobility due to a stroke. However, the care plan did not include the use of side rails, and there were no physician's orders for them, despite their installation in the resident's room. Resident #203, who was severely cognitively impaired and dependent on a wheelchair, also used side rails for mobility. The care plan did not reflect the use of side rails, even though there was a physician's order for them, and they were installed in the resident's room. Similarly, Resident #33, who was cognitively intact but dependent for all mobility, had side rails installed without a corresponding care plan or physician's order. Interviews with staff revealed inconsistencies in care plan documentation and responsibilities. The MDS Coordinator did not create separate care plans for side rails, and there was a lack of coordination among staff members responsible for writing care plans. The facility's policy on restraint use was not provided, and the Administrator acknowledged the expectation for residents with side rails to have them included in their care plans.
Improper Medication Preparation and Administration
Penalty
Summary
The facility failed to meet professional standards of quality care when an LPN prepared medications in advance and stored them in the medication cart for five residents. This practice was observed during a survey, where medications were found in cups labeled with room numbers in the second drawer of the medication cart. The facility's policy, dated May 2019, clearly states that medications should be administered to residents immediately after preparation, which was not followed in this instance. During interviews, LPN B admitted to preparing medications in advance due to a lack of computer access while passing medications. LPN C, who administered the medications, acknowledged that they were taught not to administer medications they did not prepare themselves. Despite this, LPN C administered medications prepared by LPN B to Resident #6, which included several medications for conditions such as high blood pressure and indigestion. LPN B also confirmed preparing medications for other residents, including those with conditions like BPH, depression, and dementia. The Director of Nursing and the Administrator both stated that it was unacceptable for medications to be prepared in advance and stored in the medication cart. Their expectation was that medications should be prepared and administered immediately to the residents. This deficiency highlights a significant deviation from the facility's medication administration policy, potentially impacting the quality of care provided to the residents.
Deficiencies in Personal Hygiene Care for Residents
Penalty
Summary
The facility failed to provide necessary services for residents who were unable to perform activities of daily living, specifically in maintaining personal hygiene. Three residents with severe cognitive impairments and incontinence issues were not checked for incontinence or provided with perineal care every two hours as required. Observations showed that staff repeatedly walked past these residents without offering the necessary care, resulting in one resident being found with a saturated and foul-smelling brief after several hours. Additionally, a resident who was cognitively intact but dependent on a wheelchair and required assistance with bathing did not receive regular showers. The resident reported not having a shower in two weeks due to the facility's busy schedule and their own dialysis appointments. The shower schedule indicated that the resident missed several scheduled showers, and the facility's staff acknowledged the issue of shower refusals and scheduling conflicts. Interviews with staff, including CNAs and the Director of Nursing, confirmed the expectations for providing perineal care every two hours and offering showers twice a week. However, the staff admitted to being behind on care and acknowledged the challenges in maintaining the shower schedule due to residents' therapy and dialysis commitments. The facility's failure to adhere to these care standards resulted in deficiencies in the residents' personal hygiene maintenance.
Deficiency in Resident Activity Program
Penalty
Summary
The facility failed to provide an ongoing program to support residents in their choice of activities, which affected six residents out of a sample of 15. The deficiency was identified through observations, interviews, and record reviews, revealing that residents were not offered convenient access to activities, informed when activities would occur, or encouraged to attend. The facility's Life Enrichment Philosophy emphasized person-centered care and the importance of participation and enjoyment in activities, yet residents reported a lack of engagement and awareness of available activities. Several residents, including those with cognitive impairments and physical limitations, expressed that they were not informed about activities or provided assistance to attend them. For instance, one resident who required assistance due to recent hip and knee surgery reported only being invited to one activity in 26 days. Another resident, who was dependent on a wheelchair, stated they were unaware of any activities and had only been offered one activity, which they declined. The activity logs and calendars showed inconsistencies, with many days lacking scheduled activities, particularly on weekends. Interviews with staff, including the Activities Director, revealed a lack of coordination and communication regarding activities. The Activities Director admitted to not participating in care planning and not documenting residents' participation in activities. The Director of Nursing and other staff members acknowledged that activities were primarily held on the fourth floor, where long-term care residents resided, and that residents from other floors were rarely brought to participate. This lack of accessibility and communication contributed to the deficiency in meeting residents' activity needs.
Failure to Address Significant Weight Loss in Residents
Penalty
Summary
The facility failed to recognize, treat, and notify the primary physician of significant weight loss in two residents. Resident #37 experienced a weight loss of 9.44% within less than a month, which was not documented or reported to the physician. The resident's care plan included monitoring for weight loss and dietary intake, but there was no evidence of dietary notes or physician notification regarding the severe weight loss. Observations showed the resident appeared frail, with thin legs, hands, and arms, and was not alert to their surroundings during meals. The resident's family expressed concerns about the weight loss, but staff did not provide the requested information. Resident #251 also experienced a significant weight loss of 7.62% within less than a month, but there was no documentation of dietary notes or physician notification. The resident's care plan required monitoring and reporting of weight loss due to their nutritional problems and use of a G-tube for feeding. Despite the weight loss, staff did not identify or report the issue, and there was no evidence of a plan of action in the resident's chart. Interviews with staff revealed a lack of communication and documentation regarding significant weight loss. The Registered Dietitian was not contacted by staff when significant weight loss occurred, and the CNA responsible for recording meal intake did not review care documents. The LPN and DON indicated that weight loss should be identified and reported, but there was no awareness of any residents with significant weight loss. The DON suggested a possible scale error for Resident #37's weight loss but had not verified this. Overall, the facility's failure to monitor, document, and communicate significant weight loss led to deficiencies in resident care.
Failure to Properly Assess and Manage Bed Rail Use
Penalty
Summary
The facility failed to properly assess and manage the use of bed rails for three residents, leading to deficiencies in safety and compliance with regulations. For Resident #10, the facility did not conduct a risk assessment for entrapment from bed rails before installation, nor did they obtain informed consent or a physician's order prior to the installation. The resident, who had moderate cognitive impairment and was dependent on a wheelchair, used the side rails to assist with positioning due to a stroke. Despite the resident's verbal consent being recorded, there was no documented device or restraint evaluation, and the bed's dimensions were not verified for safety. Resident #203, who was severely cognitively impaired and dependent on a wheelchair, also had side rails installed without a prior physician's order. Although a consent form was obtained and a device restraint evaluation was completed, the evaluation did not indicate that less restrictive alternatives were attempted. The side rails were installed before the physician's order was documented, and the facility failed to ensure that the bed system measurement device test results were appropriately documented. For Resident #33, who was cognitively intact but dependent for all mobility, side rails were installed without a physician's order or documented consent. The resident used the side rails for assistance with positioning, but there was no device restraint evaluation or bed system measurement results provided. The facility's process for installing side rails involved multiple staff members, including therapy, nursing, and maintenance, but lacked coordination and adherence to required procedures, resulting in the deficiencies noted.
Medication Error Due to Improper Administration Practices
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 28% error rate when an LPN prepared and another LPN administered medications for a resident. The incident involved a resident with diagnoses including pulmonary edema, chronic kidney disease, atherosclerotic heart disease, high blood pressure, and indigestion. The resident required some assistance with hygiene and showering and had a BIMS score indicating no cognitive impairment. The error occurred when LPN B prepared the 8:00 A.M. medications for the resident, and LPN C administered them, contrary to the facility's policy that only the licensed personnel who prepare the medication may administer it. The facility's Drug Administration General Guidelines policy, dated May 2019, was not followed, as LPN B prepared the medications in advance and placed them in the medication cart, which LPN C then administered. Both LPNs acknowledged their actions were against the training they received, with LPN C admitting that they should have destroyed the medications and prepared them anew. The Director of Nursing and the Administrator confirmed that the practice was unacceptable and constituted a medication error, as medications should not be prepared in advance or administered by someone who did not prepare them.
Food Storage and Safety Deficiencies
Penalty
Summary
The facility failed to adhere to professional standards of food service safety, as observed during a survey. Staff did not date the receipt of incoming food products, nor did they label, seal, and date used products. Additionally, food items were improperly stored, with some items placed directly on the floor of the dry storeroom. Expired products, leftovers, and dented cans were not properly disposed of, which could potentially expose all 58 residents to foodborne illnesses. Observations in the dry storeroom revealed numerous items without dates, including #10 cans of sliced peaches, mandarin oranges, cherry pie filling, and sliced apples, among others. There were also improperly sealed and leaking containers, such as a chocolate pudding mix that was expired and not disposed of. Additionally, a bucket of kosher pickle chips was improperly sealed and stored on the floor, and a case of orange juice was also stored on the floor. In the refrigerators, expired vacuum-packed lettuce, diced yellow onions, and various leftover foods were found, some of which were not labeled or dated. Interviews with the Dietary Manager and Dietician highlighted discrepancies between facility policy and practice. The Dietary Manager mentioned a seven-day policy for leftovers, while the Dietician expected items to be labeled with a seven-day limit before disposal. The Administrator expected food shipments to be stored off the floor and dated when opened. However, these expectations were not met, as evidenced by the numerous undated and improperly stored items found during the survey.
Inadequate Dining Space for Residents
Penalty
Summary
The facility failed to provide sufficient dining space to accommodate all residents, resulting in crowded dining room tables, lack of privacy, and some residents being turned away from dining room service. This deficiency affected four residents who were part of the sample. Observations revealed that the dining areas on multiple floors were inadequately set up, with insufficient seating and space for the number of residents wishing to dine. The main dining rooms were often full, and the overflow dining areas were not properly equipped or inviting for residents to use. Resident #250 expressed discomfort with the crowded dining conditions, particularly when seated near sick individuals. Resident #34 also noted the lack of privacy and the discomfort of being seated too closely to others with poor eating habits. Observations confirmed that the dining areas were not conducive to a pleasant dining experience, with noise from dish collection and inadequate table settings further detracting from the environment. Additionally, some residents were observed eating in their rooms due to the lack of available space in the dining areas. Residents #42 and #201 were both wheeled back to their rooms to eat after being unable to find space in the dining room. Both residents expressed a preference for dining with others, but the facility's inability to accommodate them in the dining area forced them to eat in isolation. Interviews with staff, including CNAs and the Director of Nursing, indicated that the facility often relied on residents eating in their rooms or using overflow spaces, which were not always set up for dining, to manage the lack of space in the main dining areas.
Facility Lacks Qualified Activity Director
Penalty
Summary
The facility failed to employ a qualified activity professional to oversee its activity program, as required. The current Activity Director, who has been in the position since October 2024, has not completed an approved activity professional training program. Despite having ten years of experience in long-term care as a nursing aide, the Activity Director has not received formal job-specific training for the role. Attempts to participate in scheduled monthly training calls organized by corporate staff were unsuccessful, as there was no one to lead the meetings. The facility's policy on life enrichment, which is undated, outlines the responsibility of all team members under the guidance of the Activity Director to implement minimum standards for life enrichment programming. However, the facility did not provide a policy specifically regarding activity professional training and requirements. The Administrator acknowledged the deficiency, stating that the Activity Director was expected to be qualified through state training or certification and was in the process of enrolling the Activity Director in a training program.
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What surveyors actually found near you
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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) |
|---|---|---|---|---|
| Liberty Health And Wellness | 0.1 mi | — | 0 | 0 |
| Avalon View Health And Wellness | 2.3 mi | ★★★★★ | 10 | 0 |
| Pleasant Valley Manor Care Center | 5.1 mi | ★★★★★ | 16 | 2 |
| Linden Woods Village | 7.5 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.