Liberty Commons

Inspectors wroteBased on observation, interviews, and document review, the facility failed to ensure that residents were fully aware of the grievance process. Specifically, for 11 of 11 residents attending the resident group meeting during the survey, the facility failed to ensure their grievance policy included the right to file grievances anonymously and failed to ensure residents were aware of and had access to grievance forms, and were aware they could formulate grievances anonymously, should they choose not to alert a staff member of their concern(s).

Inspectors wroteBased on review of Resident Council Minutes, a resident group meeting, interviews, and record reviews, the facility failed to ensure grievances brought forward from the Resident Council were addressed and promptly resolved to ensure the residents felt their concerns were acted upon timely and included the facility response to the group.

Inspectors wroteBased on record review and interview, the facility failed to ensure that each resident's drug regimen was free from unnecessary psychotropic medications to promote or maintain the residents' highest practicable mental, physical, and psychosocial well-being. Specifically, the facility failed to ensure for one Resident (#84), out of a total sample of 26 residents, that as needed (PRN) use of Ativan (treats anxiety) was limited to 14 days and the prescriber documented an evaluation of the Resident's current condition and the appropriateness for continued use prior to extending its duration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services consistent with professional standards for three Residents (#109, #84, #138), out of a total sample of 26 residents. Specifically, the facility failed:1. For Resident #109, to complete weekly skin assessments as ordered by the physician;2. For Resident #84, to implement a physician's order for head-of-bed elevation positioning; and 3. For Resident #138, to obtain a physician's order for an Registered Nurse (RN) pronouncement of death.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to provide residents with adequate supervision and effective interventions to prevent avoidable accidents for four Residents (#20, #24, #84, and #72), out of a total sample of 26 residents. Specifically, the facility failed:1. For Resident #20, to implement the Resident's seat/chair alarm as indicated in the Resident's care plan;2. For Resident #24, to implement the Resident's personal alarm as indicated in the Resident's care plan; 3. For Resident #84, to develop and consistently implement effective interventions to prevent four unwitnessed falls; and 4. For Resident #72, to implement the Resident's bed/chair alarm and fall mats as indicated in the Resident's care plan.

Inspectors wroteBased on interviews and record review, the facility failed to monitor the nutritional status of one Resident (#1) with an unplanned significant weight loss, out of a total sample of 26 residents. Specifically, the facility failed to identify and address a 5.27% significant weight loss in one month for Resident #1.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure all drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. Specifically, the facility failed to:1. Ensure medication carts were locked when not in direct supervision of the licensed nurse; and2. Ensure topical treatments were securely stored and not left at the bedside on one of three units in the facility.

Inspectors wroteBased on interviews and record reviews, the facility failed to notify the physician of a change in condition in order to reevaluate the potential need to alter the treatment plan for one Resident (#1), out of 26 residents sampled. Specifically, the facility failed to notify Resident #1's physician regarding a 5.27% significant weight loss over one month.

Inspectors wroteBased on observations, document review, and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment for one Resident (#12), of 26 sampled residents. Specifically, the facility failed to ensure Resident #12's continuous positive airway pressure (CPAP - used to treat sleep apnea) mask and tubing was maintained in a sanitary manner.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure all medications used in the facility were stored and labeled in accordance with currently accepted professional principles. Specifically, the facility failed to: 1. Ensure medication carts were locked when not in direct supervision of the licensed nurse; and 2. Ensure staff properly labeled all medications stored in three of four medication carts reviewed once opened.

Inspectors wroteBased on observation, interview, and document review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and potential transmission of communicable diseases and infections when the facility was currently experiencing an outbreak of COVID-19 infection. Specifically, the facility failed to: 1. Ensure staff did not report to work or provide care to residents while acutely ill without testing to ensure they were not COVID-19 positive while in the facility; 2. Test Residents in accordance with current COVID-19 testing guidelines following a known exposure for 9 of 17 residents effected; and 3. Ensure staff properly handled medications to reduce the potential transmission of pathogens for Resident #19 during medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards of practice were followed for one Resident (#19), out of a total sample of 24 residents. Specifically, the facility failed to ensure nursing staff administered medications per physician's orders and manufacturer's recommendations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment that was free from accidents and hazards for one Resident (#19), out of a total sample of 24 residents. Specifically, the facility failed to ensure unauthorized medications were not left at the bedside for the Resident, who was legally blind, to self-administer without a proper assessment of the Resident's mental and physical capabilities to reduce the risk of any potential adverse consequences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary respiratory care and services for one Resident (#12), out of a total sample of 24 residents. Specifically, the facility failed to ensure oxygen (O2) equipment was maintained to ensure sanitary conditions to help decrease the risk of potential contamination and infection.

Inspectors wroteBased on document review, policy review, and interview, the facility failed to maintain and consistently implement an infection prevention and control program for the surveillance of potential illnesses based on the facility identified McGeer criteria.

Inspectors wroteBased on document review, policy review, and interview, the facility failed to maintain professional standards for administering pain medication as ordered by a physician for one Resident (#265), out of a total sample of 23 residents.