Liberty Center for Rehabilitation and Nursing

Inspectors wroteBased on staff interviews, review of facility policy, and review of facility documentation it was determined that the facility did not ensure that a complete and thorough investigation related to abuse allegation was completed for one of twenty residents reviewed. (Resident R83)

Inspectors wroteBased on observations, review of facility policy and interview with staff, it was determined facility did not implement and maintain an effective infection prevention control program related to water management program and enhanced barrier precautions on one of four units observed. (Unit C)

Inspectors wroteBased on review of facility policy, observations, and interviews with staff it was determined that the facility did not ensure a clean, comfortable, homelike environment for two of four nursing units reviewed. (C-Wing and D-Wing)

Inspectors wroteBased on a review of clinical records, facility documentation, and interviews with staff and residents, it was determined that the facility to implement its abuse policy related to investigation and protection of residents, and to immediately protect a resident involved in resident to resident sexual abuse for one of three residents reviewed (Resident R83).

Inspectors wroteBased on observations, review of facility policy and interview with staff, it was determined that facility did not ensure to develop and implement a resident centered care plan for one of 20 residents reviewed related to psychosocial health. (Resident R21)

Inspectors wroteBased on observations, interviews with staff, and review of facility documentation it was determined that the facility did not ensure to update and implement a comprehensive centered care plan related to behaviors for one of twenty residents reviewed. (Resident R46)Findings Include: Review of the facility policy titled, Care Plans, Comprehensive Person-Centered last revised December 2016 states, Policy Statement- A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Further review of the facility policy states, g. Incorporate identified problem areas; h. Incorporate risk factors associated with identified problems. [...]

Inspectors wroteBased on observations, review of clinical records and review of facility policy, it was determined that facility did not ensure to provide activities of daily living (ADL's) assistance for two of 20 residents reviewed (Residents R34, R41)

Inspectors wroteBased on interview with resident, review of clinical records, review of facility policy and facility provided documentation, it was determined that facility did not ensure to provide adequate supervision to prevent an accident for two residents and one employee (Resident R7, R46, and Employee E19)

Inspectors wroteBased on review of facility policy, review of resident clinical records, observations, and staff interviews, it was determined that the facility did not ensure a resident received appropriate behavioral health management to maintain the highest practicable well-being for one of twenty residents reviewed (Resident R46). Findings Include: Review of facility policy titled, Behavioral Assessment, Interventions and Monitoring last revised December 2016 states, Policy Interpretation and Implementation- General Guidelines 1. Behavior is the response of an individual to a wide variety of factors. These factors may include medical, physical, functional, psychosocial, emotional, psychiatric, or environmental causes. Further review of the policy states, Assessment.3. [...]

Inspectors wroteBased on observation and staff interview, facility did not ensure proper storage of controlled substance medications for 1 of 2 medication rooms. (1st Floor)Findings Include: Observation on May 13, 2026 at 10:15 AM of the 1st floor medication room revealed only medication cart nurses and the Director of Nursing (DON), Employee E2, have keys to the medication room and to the medication room's refrigerator, with controlled substances stored inside a separate box within the refrigerator. Further observation revealed drawer containing controlled substances inside the refrigerator lacked permanent affixing to the refrigerator and was able to be removed from the refrigerator. [...]

Inspectors wroteBased on a review of the facility assessment and staff interviews, it was determined that the facility did not ensure active involvement of direct care staff and input from residents, resident representatives, and family members in the development and revision of the facility assessment. Additionally, the facility failed to identify within the facility assessment an accurate resident population with mental health and substance abuse diagnosis.

Inspectors wroteBased on observations and interviews with residents and staff, it was determined that the facility failed to provide a safe, clean and homelike environment for three of four nursing units observed (B, C and D units).

Inspectors wroteBased on review of facility documentation, observations, and staff interview it was determined that the facility failed to ensure food was stored and prepared in accordance with standards for food service safety. Findings Include: Review of facility policy Food Storage revealed temperatures for the freezer should be 0 degrees or below and must be recorded daily. A tour of the main kitchen was conducted on June 2, 2025, at 10:00 a.m. with the Food Service Director, Employee E27, which revealed the following: Observations in the outbuilding containing the walk-in freezer revealed a steel entry door that was not closed properly, and the bottom of the door was rusted through and did not seal. There was significant dirt and debris built-up within the outbuilding containing the walk-in freezer. [...]

Inspectors wroteBased on observations, interview with staff and residents, it was determined facility did not ensure the facility was maintained in a clean, safe, and homelike environment on two out of four nursing units observed (A-wing, C-Wing, D-Wing, and Dining Room).

Inspectors wroteBased on review of facility documentation, observations, and resident interviews it was determined that the facility failed to serve meals timely for one of three dining observations (June 3, 2025, breakfast meal). Findings Include: Review of facility documentation Mealtimes revealed breakfast is scheduled to be served at 8:00 a.m. Observations on June 3, 2025, at 9:26 a.m. revealed seven residents were still waiting for breakfast to be served. Resident R20 and R36 complained of being hungry. Observations on June 3, 2025, at 9:30 a.m. revealed dietary staff just began to plate meal trays from the steam table in the 1st floor dining room. Interview with the Registered Dietitian, Employee E8, confirmed breakfast was late due to dietary employees not showing up for work. Interview on June 3, 2025, at 11:30 a.m. [...]

Inspectors wroteBased on observations and interview with staff and residents as well as review of facility provided documentation, it was determined facility did not ensure to maintain effective pest control program on two out of four units observed (Units, A, C, and D).

Inspectors wroteBased on review of clinical record, observations, and staff interview it was determined that the facility failed to maintain dignity for one of eight residents during dining (Resident R70). Findings Include: Review of Resident R70's physician order summary revealed a diet order dated April 7, 2025, that the resident was NPO (nothing by mouth for food or drinks). Review of Resident R70's comprehensive care plan dated April 16, 2025, revealed the resident was allowed pudding or applesauce at lunch time only with specific feeding instructions. Continued review of Resident R70's comprehensive care plan dated December 16, 2024, revealed the resident was dependent on staff for eating, dressing, and mobility. Observations on June 4, 2025, at 12:45 p.m. [...]

Inspectors wroteBased on review of facility policy, review of clinical records, observation, and staff interviews it was determined the facility failed to ensure that residents were free from neglect for one of 8 residents reviewed relating to one employee not providing supervision and care for one resident over a period of two scheduled shifts.(resident R16)

Inspectors wroteBased on interview with residents and staff as well as review of clinical records, it was determined facility did not develop and implement a comprehensive resident centered care plan related to maintaining resident's hearing and nutrition for one of 19 residents reviewed (Resident R25)

Inspectors wroteBased on observations and review of clinical records, it was determined facility did not maintain proper grooming and personal hygiene for two of 19 residents reviewed (Resident R26, R52)

Inspectors wroteBased on interview with staff and resident, as well as review of clinical records, it was determined facility did not ensure that resident received proper treatment and assistive device to maintain hearing abilities for one of 19 residents reviewed (Resident R25)

Inspectors wroteBased on observations, review of facility policies and interviews with staff it was determined that the facility failed to maintain a safe environment free from accident hazards for one resident related to hazardous material endangering the environment and welfare for two of two residents reviewed. (Resident R44 and R68)

Inspectors wroteBased on review of clinical records and staff and resident interviews, it was determined that the facility failed to provide culturally competent, trauma care in accordance with professional standards of practice, accounting for residents past experiences and preferences in order to eliminate and or mitigate triggers that may cause re- traumatization of the resident for two of two residents sampled. (Residents R28 and R30)

Inspectors wroteBased on review of facility documentation, observations, and staff and resident interviews it was determined that the facility failed to serve the posted menu for one of three dining observations (June 2, 2025, lunch meal). Findings Include: Observations on June 2, 2025, at 1:00 p.m. revealed the posted lunch menu was a pork chop topped with apple marinade. Furter observations on June 2, 2025, at 1:00 p.m. revealed Resident R20 was served a plain pork chop without any gravy or marinade. Resident R20 subsequently requested gravy for the pork chop. Interview on June 2, 2025, at 1:05 p.m. with Activity Aide, Employee E23, confirmed what was on the posted menu and further confirmed Resident R20 did not get gravy on the pork chop. Activity Aide, Employee E23, went to kitchen for gravy but reported that the kitchen did not have any. Interview on June 2, 2025, at 1:35 p.m. [...]

Inspectors wroteBased on review of facility provided documentation, observations , and interview with staff, it was determined facility did not use its hoursekeeping resources effectively and effeciently to provide services in compliance with accepted professional standards and principles that apply to professionals providing services in the facility related to housekeeping services.

Inspectors wroteBased on observations and interview with staff and residents, it was determined facility did not implement and maintain an effective infection prevention control program related to water management, meal service and hygiene care for one of 19 residents reviewed (Resident R25)

Inspectors wroteThe facility failed to maintain essential kitchen equipment in safe, operating condition. Findings Include: Review of facility policy Food Storage revealed temperatures for the freezer should be 0 degrees or below and must be recorded daily. A tour of the main kitchen was conducted on June 2, 2025, at 10:00 a.m. with the Food Service Director, Employee E27, which revealed the following: Observations inside the walk-in freezer revealed it had a significant build-up of ice on the outside of the fan and ceiling. The hot dogs and bread were not frozen solid to touch which indicated that these food items had begun to defrost. The thermometer on the outside of the freezer was reading 32 degrees Fahrenheit (F), and the thermometer on the inside of the freezer was reading 28 degrees F. [...]

Inspectors wroteBased on review of facility policy, clinical record review and interviews with staff, it was determined that the facility failed to ensure a Level ll PASARR was conducted for residents with mental disorders as required for four of four residents reviewed. (Residents R1, R3, R20 and R36).

Inspectors wroteBased on Review of clinical record, review of facility policy and interview with staff, it was determined that the facility failed to ensure that residents were provided with education regarding the benefits and potential side effects of influenza immunization for three of three residents (Residents R85, R8 and R17).

Inspectors wroteBased on observations and staff interviews, it was determined that the facility failed to ensure a safe, functional, and sanitary environment for residents, staff, and the public on four out of four nursing units. (A, B, C, D nursing units)

Inspectors wroteBased on review of facility policies, reviewof clinical records, facility documentation, staff and resident interviews, it was determined that the facility failed to ensure that residents were free from abuse for one of 18 residents reviewed (Resident R137).

Inspectors wroteBased on review of clinical records, resident and staff interviews and review of facility policy, it was determined that the facility failed to conduct a complete and though investigation to rule out abuse related to one of one allegation of potential sexual abuse. (Resident R11)

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to ensure that the environment remained free of accident hazards for one out of the 37 residents reviewed and had residents would have appropriate supervision. (Resident R30)

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that a resident's medication regime was free from potentially unnecessary medications for one of four residents reviewed (Resident 68).

Inspectors wroteBased on review of clinical records, review of facility policy, observation, and staff and resident interviews, it was determined that the facility failed to ensure that all drugs and biologicals are stored and labeled in accordance with professional standards. For one of eighteen residents reviewed. (Resident R40).

Inspectors wroteBased on review of facility policy, review of clinical records, observations and staff interviews, it was determined that the facility failed to assess the need for specialized occupational therapy services according to the professional standards of practice for one out of one resident reviewed for rehabilitation services (Resident R18).

Inspectors wroteBased on review of facility documentation and staff interview it was determined that the facility failed to ensure a designated infection prevention (IP) works at the facility focusing only on infection control at least part time as required one or more individuals servicing as infection Preventionist responsible for the facility's infection prevention plan.

Inspectors wroteBased on observations of the food and nutrition department, and interview with staff, it had been determined that the facility failed to maintain essential food service equipment in a safe operating condition relating to a gas stove control knobs and kitchen exhaust fan. Findings Include: Review of facility policy titled Supplies and Equipment, Environmental Services revised February 2009, revealed equipment must be always ready for use at all times. An initial tour of the main kitchen conducted on July 29, 2024, at 09:35 AM with employee E 25 with Dietary director, revealed the facility had five refrigerators, four are functioning and one is out of order, and a gas oven/ grill with no knobs to be used for igniting the flame and controlling the amount gas to the range for temperature adjustment. Interview with Employee E17 on July 30, 2024, at 8:10 a.m. [...]

Inspectors wroteBased on observations, and staff and resident interviews, it was determined that the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature (second floor nursing unit). Findings Include: Interview with Resident R2, on April 30, 2024, at 11:30 a.m. revealed that the meat consistency is too chewy. I cannot swallow any of the meat because it is a weird texture. Interview with Resident R1, on April 30, 2024, at 12:00 p.m. revealed that the protein source (meat) served at the facility is very tough to chew. Interview with Resident R3, on April 30, 2024, at 12:30 p.m. revealed that the meat served for lunch is tough. Observations of dining conducted on the second-floor dining room, on April 30, 2024, at 1:00 p.m. revealed that the burger patty melts (beef patty covered with melted cheese) were pink in color and appeared undercooked. [...]

Inspectors wroteBased on observations, reviews of clinical records and review of facility policies and procedures, it was determined that the facility failed to provide adequate treatment, assessment and monitoring for the care and maintenance of an intravenous catheter in accordance with professional standards of practice for one of 7 residents reviewed (Resident CL1).

Inspectors wroteBased on clinical record review, reviews of policies and procedures and interviews with staff, it was determined that the facility failed to develop and implement a comprehensive person-centered care plan for skin alterations and skin disorders for one of three residents reviewed. (Resident Cl1)

Inspectors wroteBased on review of clinical records, facility documentation, and interviews with staff, it was determined the facility failed to provide adequate supervision consistent with the resident's needs, and professional standards of practice for an ambulatory resident diagnosed with dementia, with a history of wandering, and at risk for elopement. When not properly supervised, the resident eloped from the facility, and was found wandering the streets, for one of nine residents reviewed at risk for elopement (Resident R1). The deficiency was identified as Immediate Jeopardy past non-compliance.