Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
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 Nursing & Rehabilitation Center Of during CMS and state inspections, most recent first.
Surveyors found open, undated multi-dose pens of semaglutide and insulin glargine on two medication carts, along with an expired bottle of omeprazole tablets. Nurses assigned to these carts stated that per training and competency, they were responsible for dating multi-dose vials upon opening and discarding undated or expired medications, but each acknowledged they had not checked opening or expiration dates at the start of their shifts. The DON confirmed that nurses are expected to verify opening and expiration dates at shift start, and the Administrator stated that no expired medications should remain on the carts.
A resident with moderate cognitive impairment, whose finances were managed by a responsible party, was admitted as a private-pay resident and provided a bank statement for verification of funds. Contrary to stated practice that bank statements were not to be retained, an admissions staff member kept the statement and later accessed the resident’s bank information. A charge of approximately $373 appeared on the resident’s bank account in the name of the admissions staff member, and subsequent investigation and law enforcement review confirmed that the staff member used the resident’s bank details to pay his personal credit card and then produced a fraudulent letter to deny the transaction. The facility’s internal and external investigations ultimately substantiated misappropriation of the resident’s property by this staff member.
A facility failed to maintain accurate advanced directive documentation for a resident, resulting in a discrepancy between the resident's expressed preference for CPR and the documented DNR status. Despite the resident's moderate cognitive impairment, staff interviews revealed a lack of awareness and communication regarding the change in code status, with the Medical Director relying on documentation that was not updated by the staff.
The facility failed to post cautionary signage for two residents receiving supplemental oxygen, despite orders for continuous oxygen therapy. Observations confirmed the absence of signage, and interviews revealed confusion among staff about responsibility for placing the signs. The DON noted that a resident might have been removing the signs.
The facility inaccurately coded the MDS assessments for two residents. One resident was discharged home but was incorrectly coded as discharged to an acute hospital. Another resident, admitted with COPD and on continuous oxygen, was not coded for oxygen use on the MDS assessment. Staff interviews confirmed these errors.
The facility failed to provide two residents and their representatives with a summary of the baseline care plan within 48 hours of admission. Despite conducting care plan meetings with the Social Worker, MDS coordinator, and therapy staff, the necessary documentation was not given to the residents or their representatives. The Administrator acknowledged the oversight, noting the SW was unaware of the requirement.
Undated Multi-Dose Injectable Medications and Expired Tablets Found on Medication Carts
Penalty
Summary
Surveyors identified a deficiency in the facility’s medication labeling and storage practices involving multi-dose injectable medications and an oral proton pump inhibitor. On the 100-hall medication cart, an open and undated multi-dose vial of semaglutide was found. Manufacturer instructions for semaglutide indicated that multi-dose pens must be discarded 56 days after opening. The nurse assigned to that cart stated that nurses working the carts were responsible for discarding open and undated multi-dose vials and that, per training and competency, every nurse should place the date of opening on multi-dose vials. She acknowledged she had not checked the date of opening on the semaglutide vial in her cart at the beginning of her shift, though she reported she had not administered any open and undated medication during that shift. On the 300-hall medication cart, surveyors observed one open and undated insulin glargine pen and one open and undated semaglutide pen, despite manufacturer instructions requiring insulin glargine pens to be discarded 28 days after opening and semaglutide pens 56 days after opening. In the same cart, a half-empty container of omeprazole 40 mg tablets was found with an expiration date of 1/11/25, indicating the medication was expired. The nurse assigned to this cart stated that nurses were responsible for discarding open, undated, or expired multi-dose vials and confirmed that training required dating multi-dose vials upon opening. She admitted she had not checked the dates of opening for the insulin glargine and semaglutide pens or the expiration date of the omeprazole at the beginning of her shift, though she reported she had not administered expired medication during that shift. The DON later stated that nurses were responsible for checking opening and expiration dates at the start of their shifts, and the Administrator stated there should be no expired medications left in the carts.
Misappropriation of Resident Funds by Admissions Staff Using Bank Information
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from misappropriation of property when a staff member used the resident’s personal bank information to make a payment to his own credit card account. The affected resident was admitted in February 2025 and had an admission MDS showing moderate cognitive impairment, with the responsible party managing all finances and the resident having no access to her bank account. On 3/10/25, the resident’s responsible party observed a charge of approximately $372.94 on the resident’s bank statement that included the name of the facility’s admission Director. The responsible party later notified the facility, and on 3/13/25 at 11:30 AM the facility became aware of the allegation that a payment had been made from the resident’s account to a staff member. Interviews and record review showed that, during the admission process, the resident’s family had provided a bank statement for verification of funds. Although facility staff reported that it was not facility policy to collect or retain bank statements, the Health Information Management (HIM) staff stated that, in this case, the admission Director kept the bank statement instead of returning it to the family. The previous Business Office Manager (BOM) reported that she had been on vacation during the resident’s admission and, upon her return, she was not given any of the financial documents and did not see the bank statements in the resident’s financial folder. The Administrator later explained that the HIM staff, who was assisting with admissions and Business Office duties, had placed the financial information in a file that the admission Director subsequently accessed. Law enforcement and facility interviews confirmed that the admission Director used the resident’s bank account details obtained through his role in the admission process to make a payment of $372.96 to his personal credit card account. The Detective stated that the employee, by virtue of his position, used the resident’s bank information to pay his credit card bill and later produced a fraudulent letter from a bank attempting to show that no such transaction had occurred. The previous DON and Administrator both reported that the admission Director provided this letter during the facility’s investigation, and law enforcement later verified that the document was fake. Based on updated information from law enforcement, the facility’s initial unsubstantiated allegation was changed to substantiated misappropriation of resident property, and the staff member was charged with fraud and elderly abuse related to the unauthorized transfer of funds from the resident’s account.
Inaccurate Advanced Directive Documentation
Penalty
Summary
The facility failed to maintain accurate advanced directive documentation for a resident, leading to a discrepancy in the resident's code status. The resident, who was moderately cognitively impaired, had a signed Advance Directive form indicating a Do Not Resuscitate (DNR) status, while the electronic medical record and physician orders reflected a cardiopulmonary resuscitation (CPR)/Full Code status. This inconsistency was not identified or corrected by the staff, despite the resident expressing a preference for CPR upon readmission. Interviews with facility staff, including nurses, the Director of Nursing (DON), the Social Worker (SW), and the Medical Director, revealed a lack of awareness and communication regarding the resident's change in code status. Nurse #7 admitted to not updating the form to reflect the resident's Full Code status, and the SW was unable to locate documentation of the change in the electronic medical record. The Medical Director expressed reliance on accurate documentation, which was not ensured by the staff, leading to the deficiency.
Failure to Post Oxygen Use Signage for Residents
Penalty
Summary
The facility failed to post cautionary signage outside the rooms of two residents who were receiving supplemental oxygen, which is a necessary safety measure. Resident #63, who was admitted with chronic respiratory conditions, had an order for continuous oxygen therapy at 4 liters via nasal cannula. Observations on two separate days revealed that there was no signage indicating oxygen use outside her room. Interviews with nursing staff indicated that the responsibility for placing the oxygen signage fell on the nursing team, and it was suggested that the sign might not have been transferred when the resident changed rooms. Similarly, Resident #24, who was admitted with chronic obstructive pulmonary disease and required continuous oxygen therapy at 3 liters, also lacked appropriate signage outside her room. Observations confirmed the absence of signage on two occasions. Interviews with nursing staff revealed confusion about who was responsible for placing the signage, and it was noted that the signs were mistakenly placed at the nursing station instead of the resident's room. The Director of Nursing acknowledged the issue and mentioned that a resident in the memory unit might have been removing the signs.
Inaccurate MDS Coding for Discharge and Oxygen Therapy
Penalty
Summary
The facility failed to accurately code the discharge status on the Minimum Data Set (MDS) assessment for Resident #97. Despite the physician's discharge order and nurses' notes indicating that Resident #97 was discharged home with home health services, the MDS assessment incorrectly coded the discharge as to an acute hospital. Interviews with Nurse #1 and the MDS Coordinator confirmed the error, acknowledging that the resident had a planned discharge home. Additionally, the facility did not accurately code the use of oxygen therapy on the admission MDS assessment for Resident #24. The resident, who had a history of chronic obstructive pulmonary disease (COPD) and was dependent on supplemental oxygen, was admitted with a physician's order for continuous oxygen therapy. However, the admission MDS assessment failed to reflect this, as it was not coded for oxygen use. Interviews with Nurse #7 and the MDS Coordinator confirmed the oversight, noting that the resident was indeed on continuous oxygen therapy upon admission.
Failure to Provide Baseline Care Plan Summary to Residents
Penalty
Summary
The facility failed to provide residents and their representatives with a summary of the baseline care plan within 48 hours of admission, as required. This deficiency was identified for two residents, both of whom were admitted to the facility and had baseline care plan meetings conducted. However, there was no documentation indicating that a copy of the baseline care plan was given to the residents or their representatives. Interviews with the residents and their representatives confirmed that they did not receive the care plan documentation after admission. The Social Worker (SW) and other staff members, including the MDS coordinator and therapy staff, attended the baseline care plan meetings. Despite this, the SW admitted to not providing the necessary documentation to the residents and their representatives. The facility's Administrator acknowledged that the SW was unaware of the requirement to provide a copy of the baseline care plan, which should have been completed and shared within 48 hours of admission.
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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 Burlington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Twin Lakes Community | 1.3 mi | — | 3 | 0 |
| Edgewood Place At The Village At Brookwood | 2.7 mi | — | 0 | 0 |
| White Oak Manor - Burlington | 5 mi | — | 3 | 0 |
| Peak Resources - Alamance, Inc | 5.5 mi | — | 3 | 0 |
| Alamance Health Care Center | 5.9 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.