Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Commons Rehabilitation Center during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and altered mental status was prepared for EMS transfer when EMS personnel observed multiple live cockroaches on the resident’s body and in the bed. The resident, who required supervision for ADLs, was unaware of the insects. EMS reported that staff acknowledged a cockroach infestation. ED documentation confirmed the resident arrived with insects on him and required immediate cleaning. Staff interviews described widespread cockroach presence on med carts, in rooms, and on residents over several months, and maintenance and a pest control specialist confirmed a heavy, ongoing infestation during the period surrounding the incident.
The facility failed to maintain an effective pest control program, leading to a prolonged cockroach infestation on multiple halls and in resident rooms. Pest control invoices showed routine visits but lacked documentation of reasons for treatment or specific applications, while staff across disciplines reported cockroaches on residents, in beds, on med carts, and throughout rooms and hallways. A resident with moderate cognitive impairment who was transferred to the ED for AMS was found by EMS and ED staff to have cockroaches on his body and in his bed. NAs and housekeeping staff described a longstanding, severe roach problem, use of over‑the‑counter sprays, and absence of evening housekeeping coverage. The Maintenance Director and Administrator acknowledged months of cockroach activity, reliance on word‑of‑mouth reporting instead of a formal work‑order or monitoring system, and no adjustments to the pest control program or systematic audits despite knowing that roaches had been found on residents.
Surveyors found multiple failures in food labeling, dating, and storage in the kitchen and nourishment rooms. In the walk-in cooler and freezer, opened bags of hard-boiled eggs, breadsticks, and shredded cheese were either undated or carried old open dates. In nourishment room refrigerators, fruit lacked resident identification and date, and numerous single-serve orange juice containers were past their best-by dates. In the kitchen, several opened loaves of bread in unmarked bags, some without dates, were stored in very close proximity to open containers of sanitizing cleaning solution. The Dietary Manager and Administrator acknowledged that staff were expected to label and date all opened food and to check and discard expired items.
A cognitively intact resident was sexually abused by a cognitively impaired resident who entered her room and got into bed with her. The impaired resident, who had a history of dementia and wandering, kissed and touched the other resident inappropriately. The incident was not immediately reported or addressed by staff, and the facility became aware of the abuse two days later when the resident reported it.
Two residents experienced medication errors due to staff not following physician-ordered parameters. A resident with hypertension was given an incorrect dose of Losartan, leading to hypotension and symptoms of head pressure, neck pain, and nausea. Another resident with hypotension received Midodrine outside of prescribed parameters, though without adverse effects. The errors were linked to outdated medication cards and staff training issues.
A resident with a history of yeast infections in skin folds experienced a delay in treatment for a large excoriated area behind the knee due to inadequate skin assessments and poor communication among staff. The condition was not documented or reported to the Wound Nurse or Nurse Practitioner in a timely manner, resulting in delayed treatment.
The facility failed to maintain a safe and clean environment, with black greenish substances around commode bases and missing fluorescent overbed light covers in several resident rooms. The Maintenance Director was unaware of these issues due to a lack of communication from staff, and the Administrator acknowledged the need for improvements.
Resident Dignity Compromised by Cockroach Infestation and Insects on Resident During EMS Transfer
Penalty
Summary
The deficiency involves a failure to maintain a resident’s dignity when the resident was found with multiple live cockroaches on his body and in his bed during preparation for transfer to the hospital. The resident had moderate cognitive impairment, required a wheelchair for mobility, and needed supervision with bathing and dressing. On the day of the incident, nursing documentation showed the resident became increasingly confused and disoriented to self and place, and EMS was called for evaluation of altered mental status. When EMS personnel arrived and turned the resident, they observed an unspecified number of live insects consistent with cockroaches crawling on the resident and in his bed. EMS staff reported that facility staff acknowledged a cockroach infestation and later filed an Adult Protective Services report. The emergency department provider note documented that the resident arrived at the hospital with an unspecified number of insects on him and was immediately cleaned by nursing staff. Due to altered mental status, the resident was minimally able to participate in the evaluation and could only nod or shake his head inconsistently. Interviews with facility staff revealed that the nurse who arranged the transfer did not observe cockroaches on the resident and stated EMS did not report this to her at the time. The nurse aide assigned to the resident that day reported hearing from another aide that EMS personnel had observed cockroaches on the resident and were stomping them on the floor while preparing him for transport, and she stated it had been several hours since she last provided personal care to the resident before his transfer. Additional staff interviews and external observations confirmed ongoing cockroach activity in the facility around the time of the incident. A nurse aide reported that cockroaches were “terrible” in the fall and winter, and that she had seen cockroaches on medication carts, on residents, in beds, on ceilings, and in resident rooms, including a prior incident where a resident had a cockroach on his clothing without being aware of it. The Maintenance Director acknowledged a cockroach infestation in November and December and stated staff had reported seeing cockroaches as recently as about one month prior, including reports of cockroaches found on residents. A pest control specialist who evaluated the building in late January described the facility as heavily infested with active cockroach activity. The Administrator confirmed frequent cockroach sightings in the facility during the preceding months and acknowledged awareness that EMS had reported seeing cockroaches on a resident being transferred to the hospital.
Failure to Maintain Effective Pest Control Resulting in Cockroach Infestation on Units and Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain a pest‑free environment and to operate an effective pest control program, resulting in ongoing cockroach infestation in resident care areas and on residents. Pest control invoices from December documented weekly services and aerosol treatments on the 100 and 200 halls, but did not state the reason for treatment, what pests were being treated, or details of the specific applications. One invoice noted evidence of German cockroaches in a specific room, yet there was no documentation of staff reports of cockroach activity or targeted follow‑up. Staff interviews consistently described a longstanding, significant cockroach problem beginning in the prior summer or fall, with heavy activity in October, November, December, and January, particularly on the 100 and 200 halls. One resident, identified as having moderate cognitive impairment and requiring a wheelchair and supervision with bathing and dressing, experienced a change in condition with altered mental status and was transferred to the ED. EMS documentation for this transfer indicated that, during assessment in the facility, live insects consistent with cockroaches were observed on the resident’s body and in his bed. EMS personnel reported that when they questioned staff about a bug problem, staff confirmed that the facility had a cockroach infestation and stated there was nothing that could be done about it. The ED provider note also documented that the resident arrived with insects on him and was immediately cleaned by nursing staff. Multiple staff members, including NAs and nursing staff, reported observing cockroaches on residents, in resident beds, on medication carts, on walls, ceilings, floors, and other surfaces, and behind refrigerators and in HVAC units. Several NAs stated that cockroaches had been present "everywhere" on the 100 and 200 halls, including on resident clothing and in rooms where residents ate meals and food was often spilled. Staff also reported that housekeeping was only present during daytime hours, that over‑the‑counter household sprays were used between exterminator visits, and that everyone in the facility was aware of the pest problem. Despite this, staff frequently did not submit work orders or formal reports, assuming administration and maintenance already knew. The Maintenance Director initially denied recent pest problems but later acknowledged a cockroach infestation in November and December, primarily on the 200 hall, and admitted he had been told at some point that cockroaches had been found on residents. He stated he did not contact the pest control company, adjust the pest control program, or implement any monitoring after learning this. He also reported that he did not participate in QAPI, had no records of pest‑related work orders, and largely relied on word of mouth rather than a documented system. The Administrator similarly acknowledged frequent cockroach sightings in October and November, recognized that the contracted pest control provider was not effective, and confirmed that there was no work order system for pests, no room audits for pest activity, and reliance on word‑of‑mouth reporting and over‑the‑counter sprays by housekeeping. A pest control specialist from a new company later described the facility as heavily infested with active German cockroach activity at the time of his initial evaluation, confirming the extent of the infestation.
Improper Food Labeling, Dating, and Storage in Kitchen and Nourishment Rooms
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to improper labeling, dating, and storage of food items in the kitchen and nourishment rooms. During an initial kitchen tour with the Dietary Manager, an opened plastic bag of hard-boiled eggs was found in the walk-in cooler without a date, and in the walk-in freezer an opened undated plastic bag of breadsticks and an opened bag of shredded cheese labeled as opened on 1/9/26 were observed. The Dietary Manager stated that all food items were expected to be labeled and dated upon opening and that expired items were to be discarded. Further observations in the nourishment rooms and kitchen revealed additional issues. In the 100-hall nourishment room refrigerator, a plastic grocery bag containing apples and oranges lacked a resident name and date, and seven single-serve orange juice containers had a best-by date of 1/24/26. In the 300-hall nourishment room refrigerator, four orange juice containers with a best-by date of 1/24/26 and six with a best-by date of 1/17/26 were found. The Dietary Manager reported that Dietary Aides were responsible for daily checks of nourishment room refrigerators and stated the refrigerator had been checked that day but did not know how the expired and unlabeled items were missed. In the kitchen, three opened loaves of bread in unmarked clear plastic bags, with incomplete or missing dates, were stored on a shelf in very close proximity to two open half-full containers of sanitizing cleaning solution. The Dietary Manager confirmed that food should not be stored near cleaning solutions and that food items should be labeled and dated, and the Administrator stated he expected staff to check for and discard expired food and to label and date stored food items.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a cognitively intact female resident from sexual abuse by another resident. The incident occurred when a cognitively impaired resident entered the room of the cognitively intact resident and got into bed with her. The impaired resident kissed the other resident on the face, touched her breasts, and attempted to touch her vagina. The cognitively intact resident was initially scared, believing it might be a man, but later identified the intruder as another female resident. The cognitively impaired resident had a history of dementia and was known to wander into other residents' rooms. Her care plan included interventions for her cognitive impairment and wandering behavior, but these measures were not effective in preventing the incident. The impaired resident was not assessed to have behavioral problems or wandering during the assessment period, which may have contributed to the oversight in preventing the incident. The incident was not immediately reported or addressed by the staff on duty, as neither the nurse nor the nursing assistant on shift heard the cognitively intact resident call for help. The facility became aware of the incident two days later when the cognitively intact resident reported the abuse. The facility's initial response was delayed, and the cognitively impaired resident was placed on one-to-one supervision only after the report was made.
Medication Errors Lead to Adverse Effects for Residents
Penalty
Summary
The facility failed to prevent significant medication errors involving two residents, leading to adverse effects for one of them. Resident #223, who was admitted with a diagnosis of hypertension, was administered an incorrect dose of Losartan, a blood pressure medication. The physician's order specified a 50-milligram dose to be given via PEG tube at bedtime, with instructions to hold the medication if the systolic blood pressure was below 140 mmHg. However, Nurse #6, who was new and still in training, administered 100 milligrams instead of the prescribed 50 milligrams, and did not hold the medication despite the resident's blood pressure being 117/69 mmHg at the time of administration. This resulted in Resident #223 experiencing hypotension, with symptoms of head pressure, neck pain, and nausea. The incident with Resident #223 was compounded by a failure in communication and procedure. The order for Losartan had been changed from 100 milligrams to 50 milligrams, but the medication card was not updated because the new order was not sent to the pharmacy. As a result, the nurses continued to administer the medication based on outdated instructions. The Director of Nursing and Unit Manager #2 confirmed that the medication card still reflected the old dosage, and the error was only discovered after the resident became symptomatic. Despite the resident's refusal to go to the hospital, EMS was called, and the physician was notified. In a separate incident, Resident #47, who was admitted with hypotension, was administered Midodrine, a medication for low blood pressure, outside of the prescribed parameters. The physician's order specified that the medication should be held if the systolic blood pressure was greater than 95 mmHg. However, Nurse #7 administered the medication despite the resident's blood pressure readings being above the threshold. Although Resident #47 did not experience any adverse symptoms, the Director of Nursing acknowledged ongoing issues with staff not adhering to medication parameters, as identified by the Consultant Pharmacist in monthly reviews.
Failure to Identify and Address Skin Condition
Penalty
Summary
The facility failed to comprehensively and effectively assess a resident's skin, resulting in a delay in identifying and addressing a large, excoriated area behind the left knee of an immobile resident. The resident, who was cognitively intact and required extensive two-person assistance with activities of daily living, had a history of yeast developing in the folds of her skin. Despite a care plan that included weekly full body skin assessments, a skin evaluation by Nurse #5 on 01/04/25 did not identify any new skin issues, and the excoriation was missed due to a rushed assessment. On 01/08/25, Nurse #7 observed a large red area behind the resident's left knee, which was reported to Nurse #1 during the shift change. However, there was no documentation of this observation in the resident's medical record, and the Wound Nurse was not informed until later. The resident reported that the area had been present for a month, and no treatment had been applied. The Wound Nurse and Nurse Practitioner were only notified on 01/08/25, at which point treatment orders were implemented. The Director of Nursing confirmed that the excoriation was identified by Nurse #7 on 01/06/25 but was not properly documented or communicated to the necessary medical staff. The lack of thorough skin assessments and communication led to a delay in treatment for the resident's skin condition, which was eventually identified as a fungal infection requiring antifungal medication.
Deficiencies in Facility Maintenance and Cleanliness
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by the presence of a black greenish substance around the base of commodes in several resident rooms and missing fluorescent overbed light covers in multiple rooms. These issues were observed across four hallways during a survey. The Housekeeping Supervisor indicated that while her staff was responsible for daily cleaning, the Maintenance Department was tasked with removing such substances and handling caulking. However, the Maintenance Director was unaware of the issues, as no staff had reported them to him. During a follow-up tour with the Administrator, the same deficiencies were noted, and it was acknowledged that these issues needed to be addressed by the Maintenance Director. The Administrator expressed that improvements were being made to enhance the residents' living environment, but it would require time. The report highlights a lack of communication and coordination between the housekeeping and maintenance departments, leading to unresolved maintenance issues that compromise the residents' right to a safe and homelike environment.
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 61 citations issued within 25 miles in the last 12 months — including the 2 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 Wilmington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bradley Creek Health Center | 0.6 mi | ★★★★★ | 0 | 0 |
| Davis Health And Wellness Center At Cambridge Vill | 3.4 mi | ★★★★★ | 8 | 0 |
| Cypress Pointe Rehabilitation Center | 4.3 mi | ★★★★★ | 1 | 0 |
| Northchase Nursing And Rehabilitation Center | 4.5 mi | ★★★★★ | 0 | 0 |
| Peak Resources-wilmington, Inc | 5.1 mi | ★★★★★ | 10 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Liberty Commons Rehabilitation Center.
100% money-back within 48 hours.
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.