Below average — CMS composite of the measures below.
The next survey window likely opens around October 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Liberty Commons Nursing & Rehabilitation Center Of during CMS and state inspections, most recent first.
The facility did not consistently resolve or communicate outcomes for repeated concerns about call-light response, housekeeping, and dietary services raised by residents during group meetings. Residents reported ongoing dissatisfaction, lack of updates, and difficulty voicing dietary complaints due to the separation of Resident and Dietary Councils. Staff interviews confirmed inconsistent documentation and follow-up, with no formal records kept for Dietary Council meetings and unclear processes for informing residents of resolutions.
A resident with bilateral below the knee amputations and hemiplegia was not accurately coded for limb prostheses on the MDS assessment, despite the care plan indicating use of bilateral prosthetic legs. Staff interviews confirmed the assessment error.
A resident admitted with heart disease and chronic venous hypertension was documented as receiving oxygen by nasal cannula, but the baseline care plan did not include oxygen therapy as a focus area. Staff interviews revealed the omission was due to the lack of a physician order for oxygen in the EMR at admission, and the care plan was not updated after oxygen use was identified.
A resident with cognitive impairment and multiple medical conditions did not receive quarterly smoking assessments as required by facility policy. Although the resident was identified as a supervised smoker and staff were notified electronically of pending assessments, only two assessments were completed during the review period, and staff were unaware of the missed assessments.
A resident with a PICC line for IV antibiotics did not receive a weekly sterile dressing change as ordered. The dressing remained unchanged for over a week, with documentation marked as not applicable and staff expressing confusion about responsibility and timing. Observations and interviews confirmed the order was not followed, resulting in a deficiency related to safe IV administration.
A resident with a history of heart disease was admitted and received oxygen therapy without a physician's order, and staff failed to post required 'oxygen in use' signage outside the resident's door. Multiple nurses documented oxygen use but did not record the amount administered, and the MAR/TAR lacked documentation of oxygen therapy. Staff interviews and observations confirmed these omissions, which were attributed to oversight and lack of communication among nursing staff.
The facility did not send the required transfer notice to the LTC Ombudsman when a resident was transferred to the hospital and did not return. Interviews and record review confirmed that the Ombudsman did not receive notifications for any discharges or transfers during that month, and facility staff could not provide documentation of such notification.
A resident with cognitive impairment and urinary incontinence experienced a delay in treatment for a urinary tract infection due to a failure in the facility's process for urine specimen collection and delivery to the laboratory. The initial specimen was not picked up as expected, leading to a three-day delay in diagnosis and treatment. Interviews with staff revealed a lack of communication and follow-up regarding the specimen pickup process.
A facility failed to document the return of a discontinued medication, Hydroxyzine HCl, for a resident. The medication was prescribed for 14 days, with 20 tablets delivered and seven doses administered. However, there was no documentation accounting for the remaining 13 tablets after discontinuation. Interviews with staff revealed that the facility lacked a return to pharmacy form, and the pharmacist confirmed no record of the medication's return.
A facility failed to conduct a PASRR screening for a resident with schizophrenia and anxiety before admission. The resident had a Level II PASRR for serious mental illness, which was changed to Level I without a new screening. The facility accepted the hospital's PASRR without submitting a new request, unaware of the requirement for a PASRR evaluation prior to admission.
Two residents requiring supplemental oxygen did not have proper physician orders or signage indicating oxygen use outside their rooms. Staff interviews revealed confusion and lack of responsibility for ensuring these protocols were followed, with the DON and Administrator acknowledging the absence of a consistent Lead Nurse to oversee these procedures.
A facility failed to maintain communication with a dialysis center for a resident with end-stage renal disease. The resident's dialysis communication forms were often incomplete, lacking vital signs and medication lists. Staff interviews revealed lapses in procedure adherence, with a nurse aide unable to recall obtaining vital signs and a nurse failing to complete necessary documentation, mistakenly believing the dialysis schedule had changed.
A resident admitted with dementia, depression, and anxiety was prescribed multiple antipsychotic medications, but the facility failed to conduct necessary monitoring for side effects. The baseline care plan required an AIMS assessment, which was not completed, and monitoring was discontinued shortly after admission. Staff interviews revealed that the oversight was due to a lapse in updating orders and the absence of clinical meetings during a holiday weekend.
The facility failed to ensure complete and accurate medical records for two residents, leading to deficiencies in medication administration and pressure sore care. Nurses reported issues with the electronic MAR system, and the Wound Nurse admitted to incomplete documentation due to difficulties with the new electronic medical record system.
The facility's QAPI Committee failed to maintain procedures and monitor interventions, leading to repeat deficiencies in maintaining accurate and complete medical records. During a complaint investigation, it was found that the facility failed to ensure medical records were complete and accurate for two residents, specifically regarding medication administration and pressure sore assessment and care. Additionally, during a previous survey, the facility failed to maintain an accurate MAR for a resident.
A resident who experienced an unwitnessed fall did not receive a timely x-ray due to a communication failure and transfer to a different section of the facility. The x-ray, eventually completed, revealed significant cervical spine injuries, leading to hospital evaluation and conservative treatment.
Failure to Address and Communicate Resolutions for Resident Concerns
Penalty
Summary
The facility failed to resolve and communicate resolutions for repeat concerns raised by residents during organized group meetings, specifically regarding call-light response times, housekeeping services, and dietary services. Over a six-month period, meeting minutes and communication forms showed that concerns were repeatedly voiced by residents, but there was inconsistent or absent documentation of follow-up actions or resolutions. In several instances, only select issues were addressed, while others, such as dietary and housekeeping concerns, were not documented as resolved. Residents reported that their concerns remained unaddressed over multiple months, and they did not receive updates about any actions taken. Residents expressed ongoing dissatisfaction with the facility's handling of their concerns, particularly regarding food quality, call light response, and room cleanliness. They reported feeling unable to voice dietary concerns during Resident Council meetings due to the creation of a separate Dietary Council, which they felt was not effective. Residents described the Dietary Manager as unapproachable and dismissive, and stated that they were not informed about the outcomes of their complaints. There was also a lack of formal documentation or minutes for Dietary Council meetings, and residents could not recall when these meetings last occurred or if the Dietary Manager attended. Interviews with staff, including the Activities Director, Dietary Manager, and Administrator, revealed a lack of consistent processes for documenting, tracking, and communicating the resolution of resident concerns. The Activities Director did not bring resolved or pending issues back to subsequent Resident Council meetings and did not keep formal records of Dietary Council meetings. The Administrator was unaware of the specifics of concerns discussed in Dietary Council meetings and did not consistently document follow-up actions. This lack of communication and documentation contributed to residents' perceptions that their concerns were not being addressed.
Inaccurate MDS Coding for Prosthetics
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for a resident with bilateral below the knee amputations and a history of hemiplegia and hemiparesis following cerebral infarction. Record review showed that the resident's care plan included the use of bilateral prosthetic legs, but the quarterly MDS assessment did not indicate the presence of limb prostheses. During interviews, the MDS Coordinator acknowledged that the assessment should have reflected the resident's use of bilateral prosthetics and confirmed the coding error. The Administrator also confirmed that the MDS assessments should have been coded accurately for the resident's prosthetics.
Omission of Supplemental Oxygen in Baseline Care Plan
Penalty
Summary
The facility failed to include the use of supplemental oxygen on the baseline care plan for a resident who was admitted with diagnoses including atherosclerotic heart disease and chronic idiopathic venous hypertension with ulcers to both lower legs. Although the hospital discharge summary did not indicate the use of oxygen, nursing documentation showed that the resident was receiving oxygen by nasal cannula shortly after admission. The baseline care plan created for the resident addressed pressure ulcers, wound care, pain and anti-anxiety medications, and the use of a PICC line for IV antibiotics, but did not mention oxygen therapy as a focus area. Interviews with staff revealed that the MDS Coordinator was unaware the resident had been receiving oxygen since admission, and the omission was attributed to the absence of a physician order for oxygen in the electronic medical record at the time of admission. The MDS Nurse later assessed the resident for oxygen use but did not update the baseline care plan accordingly. The administrator confirmed that the individualized, person-centered baseline care plan should be accurate and updated as needed, and acknowledged that the omission occurred because the hospital discharge orders did not include oxygen therapy.
Failure to Complete Required Quarterly Smoking Assessments
Penalty
Summary
The facility failed to complete quarterly smoking assessments for a resident who was identified as a smoker. According to the facility's smoking policy, smoking assessments are required upon admission, quarterly, and upon any change in the resident's condition. Record review showed that the resident, who had diagnoses including hypertension, muscle weakness, dementia, and partial blindness, was admitted and coded for tobacco use on both annual and quarterly Minimum Data Set (MDS) assessments. The resident required assistance with most activities of daily living and used a wheelchair. Despite the policy, only two smoking assessments were documented within the review period, and there were missed quarterly assessments. Staff interviews revealed that Team Leaders and the Assistant Director of Nursing (ADON) were responsible for completing these assessments, with the computer system set to notify staff when assessments were due. However, both the Team Leader and the ADON were unaware that the required quarterly smoking assessments for the resident had not been completed as scheduled. The resident was observed smoking under supervision, and the care plan indicated the need for quarterly assessments, but this intervention was not consistently implemented as per policy.
Failure to Perform Timely PICC Dressing Change as Ordered
Penalty
Summary
A deficiency occurred when the facility failed to perform a weekly dressing change to a resident's peripherally inserted central catheter (PICC) as ordered. The resident, who was admitted with chronic idiopathic venous hypertension and ulcers, had a physician order for weekly sterile PICC dressing changes and daily monitoring for catheter migration. Despite these orders, there was no documentation that the PICC dressing had been changed since admission, and the Medication Administration Record (MAR) showed that the dressing change was marked as not applicable on the scheduled day. Observations confirmed that the PICC dressing remained unchanged for more than a week, with the original dressing date still present during multiple checks. Interviews with nursing staff revealed confusion regarding responsibility for the dressing change and the correct timing, with Nurse #1 stating she did not change the dressing because she believed it was not yet due and was told to record it as not applicable. Team leaders and the Assistant Director of Nursing clarified that the assigned nurse was responsible for the dressing change and that the order should have been followed as written. Further interviews indicated a lack of communication and clarity among staff regarding the implementation of the physician's order and facility policy. The Director of Nursing and Administrator both confirmed that the dressing should have been changed according to the order and policy, but this was not done. The deficiency was identified through record review, observation, and staff interviews, which established that the facility did not ensure the safe and appropriate administration of IV fluids by failing to perform the required PICC dressing change.
Failure to Obtain Physician Order and Post Oxygen Use Signage for Resident Receiving Oxygen Therapy
Penalty
Summary
A deficiency occurred when a resident with a history of atherosclerotic heart disease was admitted to the facility and began receiving oxygen therapy without a physician's order. The hospital discharge orders did not include oxygen therapy, and there was no documentation in the physician progress notes or the electronic medical record (EMR) indicating an order for oxygen. Multiple nurses documented that the resident was receiving oxygen via nasal cannula, but none recorded the amount of oxygen administered. Interviews with nursing staff revealed confusion and lack of recall regarding the presence of an oxygen order, with several staff members acknowledging that an order should have been obtained and entered into the EMR but was not done until several days after admission. Additionally, the facility failed to ensure that appropriate signage indicating 'oxygen in use' was placed outside the resident's door while the resident was receiving oxygen therapy. Nursing documentation and staff interviews confirmed that the signage was not posted, and staff could not recall why this step was missed. Observations confirmed that the resident was receiving oxygen therapy without the required signage being present on the door. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) did not reflect documentation of oxygen use for the resident during the period in question. Interviews with the Director of Nursing and other team leaders confirmed that it was the responsibility of nursing staff to ensure both the physician order and the signage were in place when oxygen therapy was initiated. The deficiency was attributed to oversight and lack of communication among the nursing staff and team leaders during the admission process.
Failure to Notify LTC Ombudsman of Resident Transfer
Penalty
Summary
The facility failed to send a required notice of transfer to the Long-Term Care (LTC) Ombudsman for one of two residents who were transferred to the hospital. Record review showed that a resident was transferred to the hospital and did not return to the facility. Interviews with the Social Services Director revealed that, although the department typically notifies the Ombudsman via email about discharges and transfers, there was no documentation in facility records confirming that the Ombudsman was notified of any discharges or transfers for the month in which the resident was transferred. The LTC Ombudsman confirmed that no notifications were received for that month, including for the resident in question. The Administrator acknowledged that the required email was not sent for that month, although documentation was available for subsequent months.
Delay in Urine Specimen Collection and Analysis
Penalty
Summary
The facility failed to ensure a collected urine specimen was delivered to the laboratory for analysis, resulting in a delay in treatment for a urinary tract infection for a resident. The resident, who was admitted with pneumonia and was moderately cognitively impaired, frequently incontinent of urine, and required assistance with toileting, complained of burning on urination. A urine specimen was collected by a nurse and placed in a refrigerator for laboratory personnel to pick up. However, the specimen was not picked up as expected, and there were no urinalysis results for the initial specimen. The laboratory patient log sheet indicated that the urine specimen was not picked up on the date it was collected, and the nursing staff was not aware that laboratory personnel would not be picking up specimens on weekends. As a result, another urine specimen had to be collected three days later, which was then picked up and analyzed. The delay in specimen collection and analysis postponed the diagnosis and treatment of the resident's urinary tract infection. Interviews with facility staff, including the nurse who collected the specimen, the administrator, and the director of nursing, revealed a lack of communication and follow-up regarding the specimen pickup process. The physician involved in the resident's care explained that antibiotics were not ordered until the urinalysis and culture and sensitivity results were available, which further delayed the start of treatment for the urinary tract infection.
Failure to Document Return of Discontinued Medication
Penalty
Summary
The facility failed to document the return of a discontinued medication, Hydroxyzine HCl, for a resident. The resident was prescribed Hydroxyzine HCl 25 mg every six hours as needed for anxiety or itching for 14 days. A total of 20 tablets were delivered to the facility, and seven doses were administered to the resident. However, there was no documentation on a medication return to pharmacy form accounting for the remaining 13 tablets after the medication was discontinued. Interviews with facility staff, including a nurse, the Assistant Director of Nursing, and the Director of Nursing, revealed that the facility did not have a return to pharmacy form indicating the return of the medication. The staff explained that discontinued medications were placed in a box for pharmacy pickup, but the return to pharmacy form was sometimes not copied for the facility's records. The pharmacist confirmed that the pharmacy had no documentation of the medication's return and stated that it was the facility's responsibility to request the necessary forms.
Failure to Conduct PASRR Screening Prior to Admission
Penalty
Summary
The facility failed to ensure that a resident with diagnoses of schizophrenia and anxiety had a Preadmission Screening and Resident Review (PASRR) conducted prior to admission. The resident, who had a Level II PASRR for serious mental illness from 2015 to 2022, was changed to a Level I PASRR on March 30, 2022. However, there was no evidence of a PASRR screening conducted since that date. The resident was admitted to the facility with severe cognitive impairment and had not received psychotropic medication in the past seven days. The facility's administrator revealed that the Level I PASRR received from the hospital was accepted without submitting a new request, as the facility's policy was to use an open and active PASRR regardless of its age. The administrator was unaware that residents with serious mental illness required a PASRR evaluation prior to admission. The marketing director confirmed that the facility accepted the hospital's PASRR and did not submit a new Level I PASRR at admission, relying on the state PASRR system's information.
Failure to Ensure Proper Oxygen Therapy Protocols
Penalty
Summary
The facility failed to ensure proper respiratory care for two residents requiring supplemental oxygen. Resident #197 was admitted with diagnoses of pneumonia and congestive heart failure, requiring oxygen therapy. However, there was no physician order for the use of oxygen in the resident's medical record, despite the resident receiving 2.5 liters per minute of oxygen via nasal cannula. Additionally, there was no signage indicating oxygen use outside the resident's room. Interviews with staff revealed confusion and lack of responsibility regarding the placement of oxygen signage, with multiple staff members acknowledging the oversight but unable to explain why it occurred. Similarly, Resident #196, admitted with pneumonia and chronic obstructive pulmonary disease, had a physician order for continuous oxygen therapy at 3 liters per minute. Despite this, there was no signage outside the resident's room to indicate oxygen use. Staff interviews indicated that the responsibility for placing the signage was unclear, with several staff members acknowledging the absence of the sign but failing to rectify the situation. The Director of Nursing and the Administrator both acknowledged the deficiencies, noting the absence of a consistent Lead Nurse to ensure proper procedures were followed. The lack of clear responsibility and oversight led to the failure to post necessary oxygen signage and obtain physician orders, compromising the facility's compliance with safety protocols for residents requiring oxygen therapy.
Failure to Maintain Communication with Dialysis Center
Penalty
Summary
The facility failed to maintain ongoing communication with the dialysis treatment center for a resident with end-stage renal disease who required dialysis. The resident was scheduled to receive hemodialysis three times per week, and the care plan included interventions such as checking for bleeding, observing for signs of infection, and assisting with transfers post-dialysis. However, a review of the resident's dialysis communication notebook revealed that 8 out of 13 communication forms were not completed by the facility staff prior to dialysis treatment. These forms lacked essential information such as pre-dialysis vital signs, weight, and vascular access details. Additionally, the dialysis center requested a current list of the resident's medications on two occasions, but the facility failed to provide this information. Interviews with facility staff revealed lapses in communication and procedure adherence. A nurse aide responsible for the resident's pre-dialysis preparation could not recall obtaining vital signs on a specific date. A nurse admitted to not completing the dialysis communication form or sending the medication list, mistakenly believing the resident's dialysis schedule had changed. The dialysis center nurse confirmed that the facility staff were not completing the necessary communication forms and had not sent the requested medication list. The Director of Nursing acknowledged that the assigned nurse was responsible for completing the communication form and sending the medication list, which was not done as required.
Failure to Monitor Antipsychotic Side Effects
Penalty
Summary
The facility failed to implement proper monitoring for side effects in a resident receiving antipsychotic medications. The resident, who was admitted with diagnoses including dementia, depression, and anxiety, was prescribed multiple antipsychotic medications such as Risperidone, Quetiapine Fumarate, Lorazepam, and Haloperidol. Despite the baseline care plan indicating the need for an Abnormal Involuntary Movement Scale (AIMS) assessment and monitoring for side effects, there was no documentation of such assessments being conducted. Additionally, the monitoring for antipsychotic side effects was discontinued shortly after the resident's admission. Interviews with nursing staff revealed that the order to monitor for antipsychotic side effects from a previous admission was not properly updated, and a new batch order for monitoring was not activated. The Director of Nursing acknowledged that the nursing staff should have completed an AIMS assessment and documented side effects on the Medication Administration Record (MAR). The oversight was attributed to the resident's admission occurring before a holiday and weekend, during which no morning clinical meetings were held to address the need for an AIMS assessment.
Deficiencies in Medication Administration and Pressure Sore Documentation
Penalty
Summary
The facility failed to ensure medical records were complete and accurate for two residents, leading to deficiencies in medication administration and pressure sore assessment and care. For Resident #2, the Medication Administration Records (MARs) from February through April 2024 showed inconsistencies and potential errors in documenting the administration of Carvedilol. Multiple nurses reported that they would not have administered the medication if the resident's pulse was below the specified threshold, yet the MARs indicated otherwise. Additionally, there were instances where the MARs were left blank without proper documentation of whether the medication was refused or the resident was away from the facility. The Director of Nursing (DON) also found her initials on the MARs despite not administering medications, suggesting a possible error in the electronic record system. For Resident #6, the facility failed to accurately document the presence and treatment of pressure sores. Upon admission, a nurse incorrectly documented a sacral pressure sore that was actually scar tissue. Furthermore, a physician's order for wound care did not specify the site initially, leading to incomplete documentation in the Treatment Administration Record (TAR). The Wound Nurse admitted to difficulties with the new electronic medical record system, resulting in missed entries for dressing changes and incorrect measurements being recorded for the sacral pressure sore. The Wound Nurse prioritized actual wound care over documentation, leading to incomplete records. The deficiencies in documentation and record-keeping were further highlighted by the interviews with the nursing staff and the DON. Nurses reported issues with the electronic MAR system, including glitches and lockouts, which may have contributed to the inaccuracies. The DON acknowledged the need for more training on the electronic medical system to prevent such errors. The incomplete and inaccurate records for both residents indicate a systemic issue with the facility's documentation practices, particularly concerning the electronic medical record system.
Failure to Maintain Accurate Medical Records
Penalty
Summary
The facility's Quality Assurance/Performance Improvement (QAPI) Committee failed to maintain implemented procedures and monitor interventions following the recertification survey. This resulted in a repeat deficiency related to the failure to maintain accurate and complete medical records. During a complaint investigation, it was found that the facility failed to ensure medical records were complete and accurate for two residents, specifically regarding medication administration and pressure sore assessment and care. Additionally, during a previous recertification survey, the facility failed to maintain an accurate Medication Administration Record (MAR) for one resident. The Administrator, who was not employed at the time of the previous citation, indicated that the nursing staff had not reported any issues with documentation accuracy in the residents' electronic medical records, preventing the QAPI program from addressing these problems effectively.
Failure to Obtain Timely X-ray for Resident After Fall
Penalty
Summary
The facility failed to obtain an x-ray as ordered for a resident who experienced an unwitnessed fall. The resident, who had multiple diagnoses including stroke, muscle weakness, and severe cognitive impairment, was found on the floor by a nurse aide. The nurse assessed the resident and found no immediate signs of pain or injury. However, the nurse practitioner later noted the resident was experiencing neck pain and ordered a cervical and lumbar spine x-ray. This order was confirmed in the electronic medical record but was not communicated to the x-ray vendor, resulting in the x-ray not being completed before the resident was transferred to the assisted living section of the facility the following day. The x-ray order did not carry over to the new record in the assisted living section, leading to a delay in the diagnostic test being performed. The resident's responsible party discovered the x-ray had not been completed during a visit and informed the nurse practitioner, who reordered the x-ray. The x-ray was eventually completed and revealed significant findings, including a cervical spine subluxation and a Type II dens fracture. The resident was then transferred to the hospital for further evaluation. The hospital confirmed the fracture and, after consulting with the family, decided against surgical intervention. The resident was placed in a cervical collar and returned to the facility for conservative treatment. Interviews with the Director of Nursing and other staff revealed that the failure to complete the x-ray was due to a misunderstanding of responsibilities. The nurse who confirmed the order in the electronic medical record assumed the nurse practitioner had contacted the x-ray vendor. This oversight, combined with the resident's transfer to a different section of the facility, resulted in the x-ray order being overlooked. The facility identified this issue and implemented a corrective action plan to prevent future occurrences.
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Illustrative
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 Benson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Carrolton Of Dunn | 8.4 mi | ★★★★★ | 5 | 0 |
| Harnett Woods Nursing And Rehabilitation Center | 8.7 mi | ★★★★★ | 0 | 0 |
| Lillington Health And Rehabilitation Center | 12.9 mi | ★★★★★ | 0 | 0 |
| Barbour Court Nursing And Rehabilitation Center | 14 mi | ★★★★★ | 6 | 0 |
| Smithfield Manor Rehabilitation And Healthcare Cen | 14.4 mi | ★★★★★ | 12 | 1 |
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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 August 2026) and official state health department websites.