Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Community Living Ctr during CMS and state inspections, most recent first.
Food Storage and Dating Deficiencies: During a kitchen observation, dry storage bins of rice and sugar were undated, bags of sugar and coffee were stored on the floor, and opened food items were kept in unlabeled, undated bags. Refrigerated items included expired chocolate milk and sour cream, and spoiled bananas were also observed. The DM acknowledged the expired items should have been discarded and confirmed that food items should be labeled, dated, and kept off the floor.
Failure to provide individualized activities on the Dementia Unit. Two residents with dementia, including one with moderately impaired cognition and one with severely impaired cognition, were observed with little to no engagement beyond watching TV and eating meals. Staff reported that scheduled activities were not being conducted, the activity board lacked times, music requested by residents was not provided during meals, and the unit's activities were often not carried out because the activities assistant was assigned elsewhere.
QAPI failed to sustain correction of a prior F812 citation for food storage practices. Surveyors again found food items that were not dated, exposed foods, and expired foods, despite the facility's QAPI plan calling for quarterly measurement and trending of key performance indicators. The Administrator stated she was unsure why the dietary dept was cited again and reported that the Dietary Manager said everything was labeled and dated with no expired foods on the shelves.
A resident with quadriplegia, who was cognitively intact, left the facility independently to get a haircut. The Administrator, responding to concerns from the resident's mother, followed the resident in her personal vehicle, took photos of the resident without consent, and sent them to the mother. Both the resident and his mother felt this was a violation of privacy, and the DON confirmed that such actions are not permitted without resident consent.
Failure to follow care plan interventions affected two residents. One resident with severely impaired cognition and ADL deficits reported not receiving daily mouth care and was observed with visible tooth discoloration, debris, and mouth odor despite a care plan for oral hygiene assistance. Another resident with dysphagia and a PEG tube had an order and care plan for daily PEG site cleansing, but an LPN cleaned only the external tubing and did not clean the insertion site; the LPN acknowledged the omission.
Failure to Provide Required Oral Hygiene: A resident with severely impaired cognition and a need for assistance with personal care reported that staff did not provide daily mouth care and did not return when she requested it. Observations showed visible discoloration, debris on the teeth, and mouth odor, and a CNA acknowledged the resident’s teeth should be brushed after every meal while the DON stated daily oral care was expected based on individual needs.
PEG site care was not performed as ordered for a resident with dysphagia and a PEG tube. An LPN cleaned only the external tubing and did not clean the insertion site, despite the order to clean the PEG site daily with warm soap and water. The LPN and DON both stated the missed cleaning could lead to infection, and the DON identified a cross-contamination issue.
Unsecured and Unlabeled Medications and Treatment Supplies: An LPN left a returned oxycodone-acetaminophen tablet on a med cart without a label or identifying information after a resident brought it back from pass, and another LPN found a wound care cart that appeared locked but opened freely and contained treatment chemicals. The DON confirmed the returned medication should have been destroyed per policy and that the wound cart had been unable to lock for months, leaving supplies accessible to residents.
A resident remained without dentures for over two months while continuing to receive a regular-texture diet with tough meats despite reporting difficulty chewing and swallowing. Staff and the dental office confirmed the resident had only an initial dental evaluation and no follow-up for denture replacement, while the DON was unaware the resident had not returned for care and the resident’s chart still ordered a regular diet with regular texture and consistency.
The facility failed to follow infection prevention practices during catheter care for one resident and PEG tube care for another resident. A CNA used the same contaminated gloves while handling catheter tubing, repositioning the resident, and touching room surfaces, and another CNA used soiled gloves on the bed remote after brief removal. An LPN performing PEG care touched the supply cart, computer mouse, feeding pump, and bedside table with gloved hands, removed and reapplied gloves without hand hygiene, and did not clean the PEG site correctly. The DON stated staff were expected to change gloves and perform hand hygiene after each care task, and that EBP were expected during PEG tube care.
A resident's trust fund was mismanaged, with unauthorized withdrawals and forged signatures discovered. The former BOM admitted to using the resident's funds for unauthorized purchases without proper receipts. The resident, who had severe cognitive impairment, had funds earmarked for funeral expenses, which were mishandled by the facility.
A resident with severe cognitive impairment experienced misappropriation of funds due to inadequate oversight by facility staff. Unauthorized withdrawals from the resident's trust fund were identified, including forged signatures and undocumented transactions. The former Business Office Manager admitted to disbursing cash without witnesses and using the resident's funds for personal purchases, contrary to facility policy.
A facility failed to report allegations of misappropriation of a resident's property to the State Agency and local authorities within the required timeframe. The issue involved a resident with severe cognitive impairment whose trust account was allegedly mismanaged, including a forged signature on a withdrawal receipt and unaccounted funds for burial expenses. Interviews revealed inadequate management and oversight of resident trust fund accounts, with staff acknowledging improper practices and lack of training.
A facility failed to investigate an allegation of misappropriation of a resident's property. The resident's representative reported unauthorized withdrawals from the trust fund account with forged signatures. The Regional Director of Operations conducted an audit but did not verify witness signatures or ensure items purchased were in the resident's possession. Staff interviews revealed unverified signatures, and the resident had severe cognitive impairment.
A facility was found deficient in food storage and labeling practices during a kitchen inspection. Observations revealed undated, exposed, and expired food items in refrigerators, a freezer, and a pantry. The Dietary Supervisor acknowledged these issues, stating it was her responsibility to monitor food quality and expiration dates, while the Administrator expected regular checks by kitchen staff.
A resident with quadriplegia and hyperhidrosis was transported in a van without functioning air conditioning, leading to discomfort during a two-hour trip. The transportation driver had informed the Administrator of the issue prior to the trip but was instructed to proceed. The resident's mother intervened during the trip to provide relief.
A CNA was observed standing while assisting a resident with eating, contrary to the facility's policy on dignified care. The DON confirmed that CNAs are trained to sit and make eye contact during feeding, but the CNA had not been trained to do so at this facility. The resident, with severe cognitive impairment and dysphagia, required careful assistance during meals.
The facility failed to provide the Notice of Medicare Non-Coverage to two residents, indicating they were not notified prior to the end of their Medicare coverage. The Beneficiary Protection Notification Reviews showed that the last covered days for these residents were not communicated properly, as the Advance Beneficiary Notices were not dated or signed. The residents had significant medical conditions, and the Business Office Manager acknowledged the oversight in the notification process.
The facility failed to properly store and date respiratory equipment, risking cross-contamination. Observations showed undated oxygen tubing and an unbagged face mask for a resident. The facility's policy lacked guidelines for tubing storage, and staff interviews revealed non-compliance with procedures requiring weekly tubing replacement and storage in a dated bag. The ADON and DON confirmed the policy's intent to reduce infection risk and emphasized staff responsibility.
The facility failed to prevent potential infection spread due to improper linen handling by CNAs. Observations showed CNAs carrying clean linen against their uniforms, violating the facility's policy. Interviews revealed the CNAs were aware of the correct procedures but did not follow them due to inattention and haste. The ADON/IP confirmed the uniforms are considered dirty, and the administrator expects adherence to the policy.
A cognitively impaired resident with a history of stroke and dementia exited an LTC facility unnoticed through a remotely opened door. The resident, assessed as at risk for elopement, was last seen near the nurses' station and followed visitors out without staff noticing. The resident was found walking near a highway and returned safely. The facility's policies required monitoring of at-risk residents, but the door was unmonitored, allowing the resident to leave.
Food Storage and Dating Deficiencies
Penalty
Summary
The facility failed to ensure food items were stored, dated, and maintained in accordance with professional food safety standards during a kitchen observation. In the dry storage room, two dry storage bins containing rice and sugar were not dated, a 25-pound bag of sugar and a 12-pound bag of coffee were stored directly on the floor, and a sugar-free no-bake cheesecake mix and a box of powdered sugar were opened and kept in clear Ziploc bags without labels or dates. The facility’s policy required dry storage items to be kept at least 6 inches off the floor, new stock to be placed behind older stock, and refrigerated and frozen foods to be dated upon delivery. In the refrigerator, 50 single-serve chocolate milk cartons were dated 10/27/25, 20 cartons were dated 11/20/25, and 76 single-serve sour cream packs stored in two brown boxes were dated 3/5/25. Nine bananas stored in a box were black with dark brown spots, and one banana was split open, black, and mushy. The Dietary Manager acknowledged the expired chocolate milk and sour cream should have been discarded on the expiration date, confirmed that no food items should be stored on the floor, that refrigerated items should be labeled and dated, that the bananas should have been discarded, and that dry storage bins were required to be dated. The Nursing Home Administrator stated she expected the Dietary Department to follow facility policy and regulatory requirements and to rotate stock daily and remove all expired food items from the kitchen.
Failure to Provide Individualized Dementia Unit Activities
Penalty
Summary
The facility failed to provide an ongoing program of individualized activities to meet the physical, mental, and psychosocial needs of residents on the Dementia Unit for two sampled residents. Resident #9 was admitted with vascular dementia and had a BIMS score of 12, indicating moderately impaired cognition. Resident #63 was admitted with unspecified dementia and had a BIMS score of 3, indicating severely impaired cognition. The facility policy stated that Life Connections programs should be resident-centered, ongoing, and include specialized activities for residents with cognitive impairment. During observations, no activities were in progress in the dayroom, and many residents were sitting with the television on. During lunch, residents including Resident #9 and Resident #63 ate without music or other sensory engagement, even though CNA #1 stated many residents had requested music during meals and the unit's CD player had been removed. Resident #9 stated music brought her peace and that staff did not come to interact with the residents, while Resident #63 stated music was soothing. The activity board listed activities without times, and Resident #9 stated she did not know what one listed activity was and that the only activity provided was watching television. CNA #1 and CNA #2 both stated that no activities were being provided and that residents mostly woke, ate, watched television, and slept. RN #1, the Dementia Unit Manager, confirmed activities were not being provided, and the Activities Assistant Coordinator acknowledged that many scheduled activities had not been conducted because he was often assigned to other duties.
QAPI Failed to Sustain Food Storage Compliance
Penalty
Summary
The facility's QAPI Committee failed to sustain corrective actions to prevent recurrence of a previously cited deficiency involving food storage practices. The facility had been cited during an annual recertification survey on 8/22/24 for F812, Food Procurement, Store/Prepare/Serve-Sanitary, after surveyors found food items that were not dated, exposed foods, and expired foods. The current survey again identified the same deficiency, showing that the facility was cited for failing to store food in accordance with professional standards for food service safety. Record review showed the facility's QAPI Plan stated that aspects of service and care are measured against established performance goals and that key performance indicators are measured and trended quarterly. The Provider History Report showed the prior F812 citation with a Plan/Date of Correction of 10/18/2024. During an interview on 12/4/25 at 10:57 AM, the Administrator stated she was unsure why the dietary department was cited again, and said that during her meetings with the Dietary Manager, she had been told everything was labeled and dated and that there were no expired foods on the shelves.
Resident Privacy Violated by Unauthorized Photography
Penalty
Summary
The facility failed to protect a resident's right to privacy when the Administrator took and shared photographs of a resident without his consent. The resident, who was admitted with quadriplegia and was cognitively intact as indicated by a BIMS score of 15, left the facility independently in his power chair to get a haircut. The Administrator, after being informed that the resident's mother was concerned about not hearing from him, followed the resident in her personal vehicle, took pictures of him at a red light, and sent these photos to his mother via text message. The resident reported feeling upset and that his privacy had been violated by these actions. The resident's mother confirmed she did not request photos and felt the Administrator's actions were inappropriate and a violation of privacy. The Administrator acknowledged taking the photos and sending them without considering the resident's privacy rights. The DON confirmed that photos should not be taken of residents without their consent and that doing so constitutes an invasion of privacy. Facility policy also states that all residents have the right to a dignified existence, self-determination, and communication, which was not upheld in this instance.
Failure to Follow Care Plan Interventions for Oral Hygiene and PEG Care
Penalty
Summary
The facility failed to implement care plan interventions related to oral hygiene for one resident and PEG care for another resident. The facility’s care plan policy stated that each resident’s care plan would remain current and inform staff of resident needs. Resident #57 was admitted with a diagnosis including need for assistance with personal care and had severely impaired cognition with a BIMS score of 6. Her care plan included oral hygiene with setup/clean and one-person assistance, but during observations she reported not receiving mouth care daily and was seen with visible discoloration and debris on her teeth and mouth odor. A CNA later confirmed the resident had visible discoloration and debris on her teeth and stated the resident’s teeth should be brushed after every meal. Resident #70 was admitted with dysphagia and had a physician’s order to clean the PEG site daily with warm soap and water. Her care plan also directed staff to clean the PEG site daily with warm soap and water and cover it with a dry dressing every day. During observation of PEG care, an LPN removed the dressing and cleaned only the external PEG tubing with soap and water, dried the tubing with gauze, and did not clean the PEG insertion site. The LPN later confirmed that not cleaning the insertion site could allow residue to build up and cause infection. The DON stated she expected staff to provide care according to the resident’s care plan.
Failure to Provide Required Oral Hygiene
Penalty
Summary
The facility failed to ensure Activities of Daily Living care, including oral hygiene, was provided for a resident who required staff assistance with oral care. The resident was admitted with a diagnosis of need for assistance with personal care and had a Quarterly MDS showing a BIMS score of 6, indicating severely impaired cognition. The facility policy stated that resident ADL care would be provided according to individualized resident needs. During observations and interviews, the resident reported multiple times that mouth care was not being provided daily and that when she asked staff for oral care, they said they would return but did not. She stated her teeth had previously been white and had become stained, and she reported the last oral care she received was several days earlier. Observations of her mouth showed visible discoloration, debris on the teeth, and mouth odor. A CNA later stated the resident should have her teeth brushed after every meal and confirmed she had visible discoloration and debris, while the DON stated daily oral care, personal care, and hygiene were expected according to individual resident needs.
PEG Site Care Not Performed as Ordered
Penalty
Summary
The facility failed to provide care and services in a manner to prevent complications for one resident with a PEG tube and dysphagia. The resident was admitted with diagnoses including dysphagia and had a physician order to clean the PEG site daily with warm soap and water. During observation of PEG tube care, an LPN removed the PEG dressing and cleaned only the external PEG tubing by wiping from bottom to top on each side with gauze saturated with soap and water, then dried the tubing with dry gauze, but did not clean the PEG tube insertion site. The resident’s quarterly MDS indicated severely impaired cognitive skills for daily decision making. During interview, the LPN confirmed that not cleaning the PEG insertion site could allow residue to build up and cause infection. The DON stated the correct purpose of PEG site cleaning was to prevent infection and that the manner in which the care was performed could cause infection and presented a cross-contamination issue.
Unsecured and Unlabeled Medications and Treatment Supplies
Penalty
Summary
The facility failed to ensure medications and biologicals were securely stored and properly labeled when a controlled substance returned by a resident was left unlabeled on a medication cart and when a wound care cart containing treatment chemicals was left unlocked and accessible to residents. Facility policy stated that medications and biologicals were to be maintained in a secured location accessible only to designated staff. During observation, a loose pill in a clear plastic sleeve labeled only with a time was found on a medication cart without the resident’s name, drug name, strength, dosage, or any other identifying information. An LPN identified the pill as oxycodone-acetaminophen 5-325 mg that Resident #10 had checked out when leaving the facility on pass and returned that morning. The LPN stated she placed the medication on the cart after the resident returned it and planned to notify the night nurse during shift report, and acknowledged it could be administered in error or diverted because it was unlabeled and unsecured. A wound care cart on the 400 hall was also observed with the lock pushed inward, but all drawers opened freely. The cart contained wound treatment supplies including triple antibiotic ointment, calamine lotion, MediHoney, and nystatin powder. An LPN confirmed the cart was not actually locked and acknowledged residents, including cognitively impaired residents, could access the unsecured chemicals. The DON stated the cart had been unable to lock since September 2025 and should not have been stored on the hallway. Resident #10’s record showed admission with quadriplegia, and the order summary included an oxycodone-acetaminophen order dated 10/10/24.
Failure to Provide Timely Dental Follow-Up and Diet Accommodation
Penalty
Summary
The facility failed to provide routine and 24-hour emergency dental care for a resident who remained without dentures for over two months and continued to receive a regular-texture diet. Resident #76 stated that his teeth had been lost in the laundry and that he had been taken to a dentist for a fitting about a month earlier, but he had not heard anything further about replacement dentures. During observation, he was served a regular lunch tray that included fried chicken, green beans, mashed potatoes, and cornbread, and he reported difficulty chewing meat without his teeth and said meals often included pork chops or other tough meats. He stated that it was hard for him to cut and swallow food without dentures, and the tray was identified as a regular diet with no accommodation for edentulism. Staff interviews and record review showed the resident had not returned for follow-up dental care after an initial dental evaluation and limited x-ray. The CNA stated the resident frequently complained that meat on his tray was hard to chew and that he could probably benefit from an easier diet for people with no teeth. The dental office confirmed the resident was seen for the initial visit but was not fitted for dentures and had not returned, and the full denture process typically takes about two months. The DON stated she was unaware the resident had not returned for follow-up, and the Administrator confirmed the resident had not gone back to the dental provider until she contacted the office after becoming aware of the issue. The resident’s record showed diagnoses including Type 2 diabetes mellitus, a BIMS score of 9 indicating moderate cognitive impairment, and an order for a regular diet with regular texture and regular consistency.
Infection Control Lapses During Catheter and PEG Tube Care
Penalty
Summary
The facility failed to implement appropriate infection prevention and control practices during indwelling catheter care for one resident and during PEG tube care for another resident. The report states that the facility’s Hand Hygiene Policy required hand hygiene by all staff to reduce the spread of infection and prevent cross contamination, and the Isolation Policy stated that Enhanced Barrier Precautions were to be used for residents with wounds or indwelling medical devices, including feeding tubes and urinary catheters, with gloves and gown worn during high-contact care activities. For the resident with a urinary catheter, a CNA washed soiled catheter tubing, rinsed it, and patted it dry while wearing the same gloves throughout the task, then touched the resident’s shoulder and thigh to reposition him without removing gloves or performing hand hygiene. In a separate observation, another CNA removed a soiled brief after a bowel movement while wearing gloves and then used the bed remote with the same soiled gloves, contaminating environmental surfaces. Both CNAs later confirmed they should have removed gloves and performed hand hygiene before touching other surfaces or repositioning the resident. The DON stated staff were expected to change gloves and perform hand hygiene after each care task and acknowledged the potential for spread of infection from the catheter area and from fecal matter to room surfaces. For the resident with a PEG tube, an LPN donned gown and gloves at the entrance and performed hand hygiene before applying gloves, but then opened the clean supply cart multiple times and used the computer mouse while wearing gloves. She placed supplies directly on the bedside table without sanitizing the surface or using a barrier, pressed buttons on the feeding pump with gloved hands, removed the PEG dressing while still wearing the same gloves, and cleaned only the tubing rather than the insertion site. She removed and reapplied gloves without hand hygiene, later returned to the room and applied gloves without hand hygiene and without donning a gown before flushing the tube. The LPN confirmed she should have washed her hands before beginning care and before re-gloving, and the DON stated the PEG site had to be cleaned correctly, a barrier should have been used on the bedside table, and EBP were expected during PEG tube care.
Mismanagement of Resident Trust Funds
Penalty
Summary
The facility failed to properly manage and secure a resident's personal funds, leading to potential misappropriation. The resident's representative reported that the resident had $3,800 earmarked for funeral expenses in a trust account at the facility. However, during a review, it was discovered that there were unauthorized withdrawals from the account, including forged signatures on receipts. The former Administrator acknowledged that a Medicaid audit revealed a significant amount of money was missing from the resident's trust fund, but did not report the issue to the State Agency, as he was reassured by the Regional Director of Operations that all funds were accounted for. The current Business Office Manager (BOM) was unable to locate receipts for several items listed on the resident's trust fund disbursement slips, including a specialty chair. The former BOM admitted to using the resident's funds to purchase items online without proper authorization and without providing receipts, only screenshots of the items. The former BOM also acknowledged that she may have been out of line in her actions and expressed willingness to reimburse the resident. The Regional Director of Operations confirmed that the procedures used by the former BOM were not in compliance with accounting standards. The resident involved had severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 3, and was diagnosed with diabetes, dementia, and disorientation. The resident's representative stated that there was no discussion about using the resident's funds to purchase a wheelchair, contradicting the former BOM's claim. The facility's failure to properly manage the resident's trust fund account and the lack of proper bookkeeping practices led to the deficiency.
Misappropriation of Resident Funds Due to Inadequate Oversight
Penalty
Summary
The facility failed to protect a resident from the misappropriation of funds, as evidenced by discrepancies in the resident's trust fund account. The resident, who was admitted to the facility with diagnoses including Diabetes, Dementia, and Disorientation, had severe cognitive impairment as indicated by low BIMS scores. The resident's representative reported unauthorized withdrawals from the trust fund, including a forged signature on a withdrawal receipt for clothing. The former Business Office Manager admitted to disbursing cash to the resident without witnesses and using the resident's funds for personal online purchases without proper documentation. Interviews and record reviews revealed multiple unauthorized debits from the resident's account, including cash advances and purchases without correlating receipts. A Medicaid audit uncovered over $3,000 missing from funds earmarked for funeral expenses. The former Administrator and RN denied involvement in the unauthorized transactions, and the former BOM acknowledged limited training in managing resident trust funds. The facility's policy on preventing abuse, neglect, and exploitation was not adhered to, resulting in the misappropriation of the resident's funds.
Failure to Report Misappropriation of Resident Funds
Penalty
Summary
The facility failed to report allegations of misappropriation of resident property within 24 hours to the State Agency and local authorities, as required by their policy. This deficiency was identified during a survey involving Resident #3, whose trust account was allegedly mismanaged. The Resident Representative (RR) reported to the former Administrator in September 2024 that her signature had been forged on a withdrawal receipt for $650.00, indicating potential fraud. Despite this report, the former Administrator did not notify the appropriate agencies, and no reimbursement was made to the resident's account. Additionally, during an audit, a Medicaid Case Manager raised concerns about unaccounted funds earmarked for burial expenses in the resident's account. Interviews with facility staff revealed a lack of proper management and oversight of resident trust fund accounts. The current Business Office Manager (BOM) and the Regional Director of Operations (RDO) both acknowledged issues with the handling of these accounts, including the absence of witness signatures on receipts and inadequate verification of transactions. The former BOM admitted to limited training and improper practices, such as providing cash withdrawals without witnesses. Furthermore, a Licensed Practical Nurse (LPN) reported being asked to sign withdrawal receipts without witnessing the transactions. Resident #3, who has severe cognitive impairment, was unable to participate meaningfully in interviews, highlighting the vulnerability of residents in such situations.
Failure to Investigate Misappropriation of Resident Property
Penalty
Summary
The facility failed to thoroughly investigate an allegation of misappropriation of resident property for one of the residents with trust fund accounts. The Resident Representative (RR) for the resident reported that money was missing from the resident's trust fund account, and unauthorized withdrawal receipts with her forged signature were found. The former Administrator was informed of the issue and indicated that it would be addressed. However, the Regional Director of Operations (RDO), who was notified, conducted an audit of the trust account but did not perform a thorough investigation. The audit did not include verifying witness signatures or ensuring that items purchased with resident funds were in their possession. Interviews with staff revealed that signatures on withdrawal slips were not verified, and some staff members denied signing the slips. The RDO admitted to not noticing unwitnessed slips or authenticating witness signatures during the audit. Additionally, the RDO did not contact the RR to verify her signature on the receipts/slips. The resident involved had severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of three. The lack of a thorough investigation and verification of signatures led to the deficiency in handling the allegation of misappropriation of resident property.
Deficiency in Food Storage and Labeling
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a kitchen inspection. The inspection revealed several issues, including undated, exposed, and expired food items. Specifically, Refrigerator #1 contained an open carton of orange juice, an opened gallon of milk, and a tub of pimento cheese spread, all with unclear or expired dates. Refrigerator #2 had unopened gallons of milk with expired dates, a plastic storage bag of cheese slices with an illegible date, and containers of leftover beef and rice with facility use-by dates. The freezer contained cups of rainbow sherbet removed from their original packaging without any dates, and the pantry had a box of exposed tea bags. Additionally, the sugar bin in the dry storage area was not securely closed, leaving the sugar exposed. During interviews, the Dietary Supervisor acknowledged the presence of outdated, exposed, and undated foods, stating it was her responsibility to monitor expiration dates and quality. She mentioned that staff members were responsible for dating food items when opened and that she conducted monthly in-service training on kitchen safety. The Administrator was also aware of the issues and expressed his expectation for kitchen staff to regularly check and manage food items to ensure proper labeling and removal of expired products.
Failure to Provide Safe Transportation
Penalty
Summary
The facility failed to provide safe and functional transportation for a resident, leading to discomfort during a transport on a hot day. The resident, who is quadriplegic and has hyperhidrosis, was transported in a van without functioning air conditioning for a two-hour trip. The resident reported feeling hot, sweaty, and lightheaded during the return trip, and his mother, who was contacted via video call, noticed his discomfort and instructed the driver to provide water. The transportation driver confirmed the air conditioning issue and reported it to the facility's Administrator prior to the trip, but was instructed to continue transporting residents. The Administrator stated that he did not recall prior knowledge of the air conditioning issue but was informed on the day of the incident. The van was repaired the following day. The resident's family member reported the incident to the Ombudsman and the Administrator. The resident was admitted to the facility earlier in the year and was cognitively intact according to a recent assessment.
Failure to Assist Resident with Dignified Feeding
Penalty
Summary
The facility failed to assist a resident with eating in a dignified manner during a dining observation. A Certified Nurse Aide (CNA) was observed standing over a resident while assisting the resident to eat during one of two meal observations. The facility's policy on Resident Rights, revised and implemented on 11/28/16, emphasizes the importance of treating each resident with respect and dignity, and caring for them in a manner that promotes their quality of life. Despite this policy, the CNA acknowledged standing while feeding the resident and stated that she was aware of the proper way to assist a resident with feeding, which is to sit, but had not been trained to do so at this facility. The Director of Nursing (DON) confirmed that CNAs are trained to position themselves in front of residents, observe, and make eye contact during assisted feeding, and that staff should not be standing while feeding. The Administrator also acknowledged the incident and stated that staff would be in-serviced on the proper way to assist residents in feeding. The resident involved, admitted to the facility on 12/28/17, had diagnoses including Vascular Dementia with other behavioral disturbances and Dysphagia. The resident's cognitive status was assessed as severely impaired, indicating a need for careful and respectful assistance during meals.
Failure to Provide Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to provide the Notice of Medicare Non-Coverage letter to two residents, indicating they were not notified prior to the end of their Medicare coverage. For Resident #12, the Skilled Nursing Facility Beneficiary Protection Notification Review showed that the last covered day of Part A Service was on 2/22/24, yet the resident remained in the facility. The Advance Beneficiary Notice of Non-coverage for this resident was not dated or signed by the resident or their representative. Resident #12 was admitted with diagnoses including Chronic Obstructive Pulmonary Disease, Parkinson's Disease without Dyskinesia, and Heart Failure. Similarly, for Resident #34, the Beneficiary Protection Notification Review indicated the last covered day of Part A Service was on 3/1/24. The Advance Beneficiary Notice of Non-coverage for this resident was also not dated or signed by the resident or their representative. Resident #34 was admitted with diagnoses including Malignant Neoplasm of an unspecified part of the bronchus or lung and Adult Failure to Thrive. The Business Office Manager stated that the forms are typically reviewed with the resident or their representative a week before coverage ends, but this procedure was not followed in these cases.
Failure to Properly Store and Date Respiratory Equipment
Penalty
Summary
The facility failed to adhere to professional standards of practice for storing and dating respiratory equipment, leading to potential cross-contamination risks. During observations, it was noted that the oxygen tubing attached to a resident was not dated, and a face mask, which was not in use, was left hanging from the wall without being bagged. This was observed on two separate occasions. The facility's Oxygen Administration policy, dated August 25, 2014, did not include guidelines for handling and storing oxygen tubing, contributing to the oversight. Interviews with staff revealed a lack of compliance with the facility's policy, which requires replacing respiratory tubing weekly and storing it in a dated plastic bag when not in use. An LPN admitted to never having seen a bag for storing the tubing since starting at the facility. The ADON confirmed that the policy is in place to reduce the risk of exposure to infectious diseases and emphasized that it is the responsibility of all nurses to adhere to it. The DON stated that new employees receive training on these procedures, and it is the cart nurse's responsibility to manage the tubing, typically changed on the Sunday night/Monday morning shift.
Infection Control Breach in Linen Handling
Penalty
Summary
The facility failed to adhere to its infection prevention and control program, specifically in the handling and transportation of linen, which could potentially lead to the spread of infection. The facility's policy, revised in August 2009, mandates that linen, whether clean or soiled, should not touch clothing or uniforms and should be handled as though it is potentially infectious. However, during observations, two Certified Nursing Assistants (CNAs) were seen transporting clean linen in a manner that violated this policy. CNA #2 was observed hugging clean linen to her uniform while moving down the 400 hall, and CNA #1 was seen carrying towels wrapped up against her uniform down the 100 hall. Interviews with the CNAs revealed that they were aware of the proper procedures but failed to follow them due to inattention and haste. CNA #2 admitted to not paying attention and confirmed that her actions contaminated the laundry. Similarly, CNA #1 acknowledged that she was moving quickly and forgot the correct procedure, admitting that carrying the towels against her uniform contaminated them. The Assistant Director of Nursing/Infection Preventionist confirmed that the staff should transport clean and dirty laundry in a bag away from their uniforms, as the uniforms are considered dirty. The facility administrator also stated that he expects CNAs to adhere to the policy when transporting linen.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent a cognitively impaired resident from exiting the facility unnoticed and unsupervised. The incident involved a resident with a history of cerebral infarction, dementia, and disorientation, who was assessed as being at risk for elopement. On the day of the incident, the resident was able to exit the facility through a remotely opened front door, which was opened by staff to allow visitors to enter. The staff were unaware of the resident's absence until a family member of another resident reported seeing the resident near a highway. The resident was last seen by an LPN near the nurses' station shortly before the incident, and there were no signs of exit-seeking behavior noted. However, the resident followed a family out of the front door unnoticed. The facility's investigation revealed that the door was not monitored at the time, allowing the resident to leave the facility without being detected. The resident was found walking along a highway approximately 0.44 miles from the facility and was returned without incident. The facility's policies on emergency procedures for missing residents and elopement/unsafe wandering were reviewed, indicating that residents at risk for wandering should be monitored, and visual supervision may be necessary. Despite these policies, the resident's cognitive impairment and wandering behavior contributed to the elopement, as the resident intended to go to a store in town. The facility's interdisciplinary team determined that the resident's cognitive impairment led to a lack of safety awareness, and the circumstances around the incident included visitors and family members going in and out of the facility.
Removal Plan
- Resident #1 was placed on visual monitoring and all other residents identified as an elopement risk were put on checks.
- Resident #1's Resident Representative was notified of the incident.
- The Medical Director was notified of the elopement and Resident #1's nurse completed a body audit.
- The Administrator checked all the exit doors for proper functioning and noted that all doors and windows were secure. The door codes were changed as a precautionary measure and the perimeter was checked.
- The facility checked to make sure that there were no other residents unaccounted for.
- The DON and Administrator initiated in-services on elopement/missing resident policies and procedures, including door monitoring and the emergency procedures for missing residents and began elopement drills.
- The staff were not allowed to work until completion of the in-services and elopement drills.
- The DON, MDS Nurses, Licensed Nurses, and Social Worker began assessing all other residents for elopement risk.
- Assessments were completed and the additional residents identified to be at risk for elopement were added to the facility's Elopement Books.
- The MDS Nurse updated the care plan for Resident #1 and all other residents identified as at risk for elopement.
- An emergency QAPI committee meeting was held regarding the elopement of Resident #1. The committee reviewed the incident, actions taken, and the facility's policy on Elopement and Wandering.
- Signs were placed on all exit doors instructing visitors to notify staff of any resident seeking assistance in exiting the facility.
- The Social Services Director and the DON ensured pictures in the facility's Elopement Books were current.
- Resident #1 was assessed by the Psychiatric Nurse Practitioner, and a new medication was added to manage Resident #1's increased anxiety.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 29 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Liberty
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wilkinson County Senior Care | 17.1 mi | ★★★★★ | 1 | 0 |
| Camellia Estates | 19.8 mi | ★★★★★ | 5 | 0 |
| Mccomb Community Care Center | 20 mi | ★★★★★ | 1 | 1 |
| Meadville Convalescent Home | 20.8 mi | ★★★★★ | 7 | 0 |
| Courtyard Health And Rehabilitation | 21.6 mi | ★★★★★ | 3 | 3 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.