Liberty Care & Rehabilitation Center

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to maintain 1 (south side nourishment room refrigerator) of 2 nourishment room refrigerators in a clean and sanitary manner.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure 1 (Resident #34) of 5 sampled residents reviewed for unnecessary medications was assessed for self-administration of medication.

Inspectors wroteBased on interview, record review, and review of the facility's policies, the facility failed to review and revise the comprehensive care plan (CCP) for three (3) of 42 sampled residents, (Residents (R), R29, R37, and R49). Although staff was aware R37 had a history of grabbing onto the wheelchair wheels of her Evolution Mobility wheelchair when she did not want to be transported by staff, the facility did not revise her Comprehensive Care Plan (CCP) with safety interventions to prevent injury related to this behavior. On 06/09/2024, R37 was being transported by staff to her room when her hand was caught in the wheel spokes of her wheelchair, causing her to sustain a fracture and lacerations to her left index finger. Additionally, R29 sustained a fall on 06/10/2024 when searching for something in his closet, causing a skin tear to his right forearm (RFA). [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for two (2) of eight (8) sampled residents reviewed for accidents out of a total sample of 42 residents, Resident (R), R29 and R37. On 06/09/2024, during transfer back to R37's room, staff allowed the resident's left hand to become entangled in the Evolution Mobility (brand of wheelchair) wheelchair's wheel spokes. The resident was transferred to the local Hospital Emergency Department and was noted to have two (2) lacerations on the left second finger. One (1) laceration, measured 2.0 centimeters (cm), with exposed bone in the proximal region of the finger, while the other, measured 1.5 cm, and was located at the medial joint. [...]

Inspectors wroteBased on observation, interview, and review of the facility's documents and policies, the facility failed to provide a clean and homelike environment for residents. Observations on 06/10/2024 and 06/11/2024, revealed the facility failed to ensure the interior of the building including residents' room walls and residents' room doors were in good repair. The observations revealed peeling paint or missing paint on the walls and some areas had wood missing from the doors leaving rough edges or gouges. Additionally, residents' rooms and bathrooms had a strong odor of urine. This affected the rooms and/or bathrooms for rooms 216, 217, 218, 219, 220, 221, 222, 223, 224, 225, and 226. Additionally, the shared bathroom between rooms [ROOM NUMBERS] had two (2) open urinals containing urine, hung on the handrail which were not bagged. One (1) of the urinals was not labeled for identification.

Inspectors wroteBased on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, review of the Manufacturer's Instructions for use of the Assure Platinum Blood Glucose Monitoring System and review of the facility's policies, the facility failed to develop and implement an ongoing infection prevention and control program (IPCP) to prevent, recognize, and control the onset and spread of infection to the extent possible. The facility failed to develop a water management program based on nationally accepted standards, specific to their building description, in order to prevent, detect and control water-borne contaminants and reduce Legionella growth. This had the potential to affect the entire population of the facility. [...]

Inspectors wroteBased on interview, record review, and review of the facility's policy, the facility failed to make the appropriate Level II Preadmission Screening and Resident Review (PASARR) referral based on the positive Level 1 PASARR screening results for one (1) of two (2) sampled residents reviewed for PASARR Screening (Resident (R)19) out of a total sample of forty-two residents. The facility assessed R19 to have a positive Level I PASARR screen at admission on [DATE]. This screening indicated the resident required a Level II Screening; however, the facility failed to ensure a Level II Screening was completed in the required timeframe.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming, and personal and oral hygiene for two (2) of 42 sampled residents, Resident #55 and #55 (R55 and R58). R55 complained on 06/12/2024, staff had not brushed her teeth or swabbed her mouth, and she did not receive assistance with mouth care very often. R55 further complained she was given a bed bath twice a week and her privates were washed only when she had a bowel movement. Additionally, observation of R58, on 06/10/2024 and 06/11/2024, revealed his fingernails were long and dirty and he had not been shaved. R58 was wearing the same dark gray shirt both days.

Inspectors wroteBased on observation, interview, and review of the facility's policy, the facility failed to ensure residents requiring respiratory care received care consistent with professional standards of practice for one (1) resident reviewed for respiratory care out of a total of 42 sampled residents, Resident #58 (R58). Observation on 06/10/2024 and 06/11/2024, revealed R58 was receiving oxygen at two (2) liters per minute per nasal cannula as per Physician's Orders. However, the oxygen tubing was not dated.

Inspectors wroteBased on interview, record review, and review of facility policy, the facility failed to have prescribed medications available to administer for one (1) of 42 sampled residents, Resident #332 (R322). R322's Physician's Orders, dated 06/07/2024, untimed, revealed orders for rifampin 300 milligrams (mg), two (2) tablets, to be administered daily between 7:00 AM and 11:00 AM. However, the medication was not delivered to the facility until 06/10/2024 at 8:15 PM, four (4) days after it was ordered. Refer to F761.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, the facility failed to ensure residents were free of significant medication errors for one (1) of 42 sampled residents, Resident 332 (R322). On 06/07/2024, R322 was prescribed two (2), 300 milligram (mg) tablets of rifampin (antibiotic to treat Tuberculosis) to be given once daily. However, R322 received half the dose (1 table, 300 mg) on 06/11/2024, and 06/12/2024.

Inspectors wroteBased on observation, interview, and review of the facility's policy, the facility failed to ensure drugs and biological's used in the facility were labeled, dated, and stored in accordance with currently accepted professional principles for one (1) of four (4) medication carts. Observation of the North Wing's A-C Medication Cart, on [DATE] at 10:15 AM, revealed two (2) opened vials of Insulin Glargine U100 with no opened date.

Inspectors wroteBased on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents were protected from abuse, including resident to resident abuse for four (4) of seven (7) sampled residents (Resident #1, Resident #2, Resident #6, and Resident #7). 1. On 09/05/2023, Resident #2 was observed by staff in Resident #1's bed (a resident of the opposite sex) with his/her hand in Resident #1's genital area. In addition, facility staff confined Resident #1 and Resident #2 to their rooms after the incident in order to allow one (1) staff member to monitor both residents at the same time. 2. On 04/16/2023, Resident #2 was observed by staff sitting on Resident #6's bed with his/her hands under a blanket covering Resident #6's lap. 3. On 09/14/2023, Resident #6 was observed by staff to hit Resident #7 in the chest area. [...]

Inspectors wroteBased on interview, record review and review of the facility's policy, it was determined the facility failed to ensure allegations of abuse were reported to the State Agencies and local law authorities immediately, but no later than two (2) hours, after the allegation was made for four (4) of seven (7) sampled residents (Resident #1, Resident #2, Resident #6, and Resident #7). 1. On 09/05/2023, Resident #2 was observed in Resident #1's bed (a resident of the opposite sex) with his/her hand in Resident #1's genital area. However, the facility failed to notify the appropriate State Agencies and local law authorities. 2. On 04/16/2023, Resident #2 was observed sitting on Resident #6's bed with his/her hands under a blanket covering Resident #6's lap. However, the facility failed to notify the appropriate State Agencies and local law authorities. 3. [...]

Inspectors wroteBased on interview, record review, review of the facility's policies, review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, and review of the Minimum Data Set (MDS) Coordinator Job Description, it was determined the facility failed to ensure a comprehensive person-centered care plan was developed and implemented to meet a resident's medical, nursing, and mental and psychosocial needs for four (4) of seven (7) sampled residents (Resident #1, Resident #2, Resident #6, and Resident #7). 1. On 09/05/2023, Resident #2 was observed in Resident #1's bed (a resident of the opposite sex) with his/her hand in Resident #2's genital area. [...]

Inspectors wroteBased on interview, record review, review of the Director of Nursing and Administrator's Job Description, and review of the facility's policies, it was determined the facility failed to ensure it was administered in a manner to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychological well-being of each resident and to ensure prevention of abuse. Staff interviews and record review revealed the facility failed to provide adequate supervision to residents to prevent abuse, failed to ensure the Comprehensive Care Plans (CCPs) were developed and implemented to prevent abuse, and failed to notify the appropriate State Agencies and local law authorities of allegations of abuse. [...]

Inspectors wroteThe facility failed to ensure implementation of the comprehensive care plan for two (2) of twenty (20) sampled residents (Residents #6 and #78). The care plan for Residents #6 and #78 required staff to ensure the resident's urinary catheter bag was covered. However, observations of the residents revealed the residents did not have urinary catheter drainage bag privacy/dignity covers as was care planned for each resident.