Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Liberty Commons during CMS and state inspections, most recent first.
The facility failed to ensure proper storage and labeling of medications, leaving carts unlocked and medications unlabeled with expiration dates. A Unit Manager left a cart unattended, and opened medications like Lantus insulin and timolol eye drops were not labeled with opening or expiration dates. Nurses were unsure of labeling requirements, and the DON acknowledged incorrect processes for test strip expiration dating.
The facility failed to maintain an effective infection prevention and control program during a COVID-19 outbreak. Staff, including a CNA, worked while symptomatic, exposing residents to the virus. The facility did not follow CDC testing guidelines for exposed residents, with inconsistencies in testing dates and documentation. Additionally, a nurse improperly handled medications, increasing contamination risk.
A resident with a history of malignant neoplasms and COPD did not receive medications per physician's orders. Nurse #1 administered only one puff of Asmanex instead of two and failed to instruct the resident to rinse their mouth afterward. The nurse admitted to being nervous under observation, and the DON confirmed the need to follow physician's orders.
A legally blind resident was found with unauthorized medications at their bedside without a proper assessment of their ability to self-administer. The facility's policy requires such an assessment, which was not conducted. The resident, with chronic kidney disease and heart failure, self-administered eye drops and antacids without physician orders or proper storage. Staff were unaware of the medications, and no assessment was done to ensure safe self-administration.
A resident requiring supplemental oxygen for comfort was found with nasal cannula tubing resting on the floor, exposing it to contaminants, and the oxygen concentrator was dusty. The resident, who was legally blind, needed staff assistance to manage the equipment. Staff acknowledged the tubing should have been stored properly and the concentrator cleaned regularly, but there was no specific order for these actions.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that all medications were stored and labeled according to accepted professional principles. Specifically, medication carts were left unlocked and unattended, and medications were not properly labeled with expiration dates once opened. On one occasion, a Unit Manager left a medication cart unlocked and unattended while retrieving an over-the-counter medication, acknowledging the oversight during an interview. The Director of Nursing confirmed that medication carts should be locked when unattended. Additionally, the facility did not label medications with shortened expiration dates once opened. During a review of the Oyster Pond medication cart, a bottle of Assure Platinum glucometer test strips was found opened and unlabeled with the date of opening or expiration. The Unit Manager was unsure of the labeling requirements and the duration for which the test strips remained viable. Similar issues were observed with the Pleasant Bay East and North medication carts, where opened vials of Lantus insulin and timolol maleate eye drops were not labeled with the date of opening or expiration. Nurses acknowledged the oversight and expressed uncertainty about the labeling requirements and the duration of medication viability. The Director of Nursing admitted that the facility's process for labeling test strip bottles was incorrect, as they were using the manufacturer's expiration date instead of the 90-day period post-opening. The DON also confirmed that Lantus insulin is only good for 28 days after opening, and although unsure about the eye drops, acknowledged that they should have been labeled with the date of opening. The purpose of these short expiration dates is to maintain medication potency and prevent contamination.
Infection Control Deficiencies During COVID-19 Outbreak
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program during a COVID-19 outbreak. Staff members, including a Certified Nurse Assistant (CNA), reported to work while experiencing symptoms consistent with COVID-19, such as nasal congestion, headache, and shortness of breath. The CNA worked a shift while symptomatic and only tested for COVID-19 after feeling progressively worse, resulting in a positive test. This action exposed several residents to the virus, as the CNA had close contact with them during her shift. The facility's policy required symptomatic staff to test for COVID-19 before starting work, but there was no evidence that the CNA was educated on this requirement. The facility also failed to adhere to COVID-19 testing guidelines for residents following known exposure. Nine residents were exposed to COVID-19 positive staff members, but the facility did not conduct testing in accordance with the Centers for Disease Control and Prevention (CDC) guidance. The residents were not tested within the recommended timeframe of 24 hours after exposure and every 48 hours thereafter. The facility's records showed inconsistencies in testing dates and a lack of documentation for some scheduled tests, indicating a failure to follow the established testing protocol. Additionally, the facility did not ensure proper handling of medications to prevent potential transmission of pathogens. During a medication administration, a nurse picked up pills that had fallen onto a resident's bedding with her bare hands and administered them without performing hand hygiene or wearing gloves. This action violated infection control practices and increased the risk of contamination. The nurse acknowledged the mistake, and the Director of Nursing confirmed that the medications should have been disposed of and replaced.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure professional standards of practice were followed in the administration of medications for a resident. Specifically, the nursing staff did not administer medications per the physician's orders and manufacturer's recommendations. The facility's policy on medication administration emphasizes the importance of the 'Five Rights' and a triple check process to ensure the correct administration of medications. However, during an observation, Nurse #1 administered only one puff of Asmanex Twisthaler to a resident instead of the prescribed two puffs and did not instruct the resident to rinse their mouth after inhalation, as required by the physician's orders and the manufacturer's guidelines. The resident involved had a history of malignant neoplasms and chronic obstructive pulmonary disease, and was cognitively intact. The physician's orders specified that the resident should receive two puffs of Asmanex daily and rinse their mouth afterward to reduce the risk of candidiasis. During the survey, Nurse #1 initially administered only one puff and failed to offer water for rinsing. Upon the surveyor's intervention, the nurse administered the second puff. The nurse admitted to being nervous under observation and acknowledged the oversight. The Director of Nursing confirmed that staff should adhere to physician's orders for medication administration.
Failure to Ensure Safe Medication Administration for Legally Blind Resident
Penalty
Summary
The facility failed to provide a safe environment free from accident hazards for a resident who was legally blind. The resident was found with unauthorized medications at the bedside, including Refresh artificial tears and TUMS antacids, without a proper assessment of their ability to self-administer these medications. The facility's policy requires an assessment of a resident's mental and physical capabilities before allowing self-administration of medications, which was not conducted in this case. The resident, who was admitted with chronic kidney disease stage 3 and chronic diastolic heart failure, was observed with medications on their overbed tray table. The resident claimed to self-administer the medications as needed, despite being legally blind and unable to specify the dosage or frequency of use. There was no physician's order for the eye drops, and the antacids were not authorized for bedside storage or self-administration. Interviews with facility staff, including a nurse and the unit manager, revealed a lack of awareness about the medications at the resident's bedside. The staff admitted that no assessment had been conducted to determine the resident's capability to self-administer medications safely. The Director of Nursing confirmed that an assessment should have been performed and that medications should be stored securely, but this was not done for the resident in question.
Failure to Maintain Sanitary Conditions for Oxygen Equipment
Penalty
Summary
The facility failed to provide necessary respiratory care and services for a resident, specifically in maintaining oxygen equipment in sanitary conditions. The resident, who was cognitively intact but legally blind, required supplemental oxygen for comfort due to shortness of breath. Observations revealed that the nasal cannula tubing was left on the floor, exposing it to potential contaminants, and was not stored in the protective bag as per facility policy. Additionally, the oxygen concentrator was observed to be dusty, indicating a lack of regular cleaning. Interviews with the resident and staff confirmed that the resident needed assistance with the oxygen equipment due to impaired vision and inability to operate it independently. Nurse #5 acknowledged that the tubing should not have been on the floor and should have been stored properly, and that the concentrator should be wiped down regularly. However, there was no specific order for cleaning the concentrator, and the Director of Nursing confirmed that while the machines do get dusty, there was no directive to clean them on an as-needed basis.
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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 North Chatham
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cape Cod Post Acute Care | 3.1 mi | — | 0 | 0 |
| Regalcare At Harwich | 6.3 mi | — | 6 | 0 |
| Windsor Nursing & Retirement Home | 11.2 mi | — | 6 | 0 |
| Mayflower Place Nursing & Rehabilitation Center | 15.3 mi | — | 8 | 0 |
| Pavilion , The | 18.5 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.