Liberty Commons Nursing & Rehabilitation Center of

Inspectors wroteBased on record review, and interviews with residents and staff, the facility failed to resolve repeat concerns and/or to communicate the facility's efforts to address concerns voiced during organized resident group meetings (Resident Council and Dietary Council) related to call-light response times, housekeeping services, and dietary services during 6 of 6 monthly meetings (May 2025, June 2025, July 2025, August 2025, September 2025, and October 2025).

Inspectors wroteBased on record review and staff interviews, the facility failed to accurately code a Minimum Data Set Assessment for prosthetics for 1 of 24 residents reviewed for accuracy of assessments (Resident #12).

Inspectors wroteBased on record review and staff interviews, the facility failed to include the use of supplemental oxygen on the baseline care plan for 1 of 2 residents reviewed for baseline care plans (Resident #54).

Inspectors wroteBased on record review and staff interviews, the facility failed to complete quarterly smoking assessments for 1 of 1 resident reviewed for smoking (Resident #23).

Inspectors wroteBased on record review, observations, and staff and Physician interviews, the facility failed to perform a weekly dressing change to a resident's peripherally inserted central catheter (PICC), a long, thin tube inserted through a vein in your arm and passed through the larger veins near your heart to deliver medication and/or treatment, as ordered for 1 of 1 resident sampled for receiving antibiotics intravenously (inside the vein) through a PICC line (Resident #54).

Inspectors wroteBased on record review, observations, and resident and staff interviews, the facility (a) failed to obtain a physician order for the use of oxygen and (b) failed to place signage outside the resident's door indicating the use of oxygen for 1 of 2 residents reviewed for oxygen use (Resident #54).

Inspectors wroteBased on record review, and staff and Ombudsman interviews, the facility failed to send a copy of the notice of transfer to the Long-Term Care (LTC) Ombudsman for 1 of 2 residents transferred to the hospital (Resident #103).

Inspectors wroteBased on interviews with staff and record review, the facility failed to ensure 1 of 1 resident (Residents #58) who had diagnoses of schizophrenia and anxiety had a Preadmission Screening and Resident Review (PASRR) prior to admission.

Inspectors wroteBased on record review, staff interviews, and a physician interview, the facility failed to ensure a collected urine specimen was delivered to the laboratory for an analysis for 1 of 1 resident reviewed for urinary tract infections and urinary catheters. This resulted in another urine specimen having to be collected for analysis and delayed the start of treatment for a urinary tract infection (Resident #73).

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to ensure there was a physician order for the use of supplemental oxygen (Resident #197) and failed to post signage indicating the use of oxygen outside residents' rooms (Resident #197 and Resident #196) for 2 of 3 residents reviewed for oxygen use.

Inspectors wroteBased on record review, staff interviews, and interview with Dialysis Center Nurse, the facility failed to maintain ongoing communication with the dialysis treatment center for 1 of 1 resident reviewed for dialysis (Resident #69).

Inspectors wroteBased on record review, staff interviews and a pharmacist interview, the facility failed to document the return of a discontinued medication, Hydroxyzine HCl (an antihistamine used to help control anxiety or symptoms of itching) to the pharmacy for 1 of 1 resident (Resident #73) reviewed for the provision of pharmacy services.

Inspectors wroteBased on record review and staff interviews, the facility failed to implement monitoring for the side effects for a resident receiving antipsychotics (medications used to treat mental disorders) for 1 of 5 residents reviewed for unnecessary medications (Resident #197)

Inspectors wroteBased on record review and staff interviews for two of ten sampled residents (Residents # 2 and # 6) the facility failed to ensure medical records were complete and accurate regarding medication administration (Resident # 2) and pressure sore assessment and care (Resident # 6).

Inspectors wroteBased on record review and staff interview the facilities Quality Assurance/Performance Improvement (QAPI) Committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification survey of 2/25/22. This was for one repeat deficiency. The area of deficiency dealt with failure to maintain accurate and complete medical records. The continued failure of the facility during two federal surveys over the course of two years showed a pattern of the facility's inability to sustain an effective Quality Assurance/Performance Improvement program.

Inspectors wroteBased on record review, and interviews with staff, family, and physician the facility failed to obtain an x-ray as ordered when a resident fell. This was for one (Resident # 1) of three residents reviewed for completion of diagnostic tests.

Inspectors wroteBased on observation, record review, resident, staff, paramedic, and physician interview the facility failed to notify the physician regarding a significant change in condition for one (Resident # 3) of two sampled residents. On the morning of 9/27/23 Nurse Aide #1 and Nurse #3 observed signs Resident # 3 was experiencing a significant change in condition including a low blood pressure, slurred speech, sluggishness, inability to carry on a conversation per his norm, inability to help in his care per his norm, and bloody urine in his catheter. The physician was not notified when staff noted the change in condition. [...]

Inspectors wroteBased on observation, record review, resident, staff, paramedic, and physician interview the facility failed to effectively assess and address a significant change in condition for one (Resident # 3) of two sampled residents whose condition necessitated Emergency Medical Services (EMS) to be called. Resident # 3 had a history of sepsis (when an infection triggers widespread inflammation in a person's body which can lead to organ damage) and on the morning of 9/27/23 Nurse Aide #1 and Nurse #3 observed Resident # 3 was experiencing a change in condition prior to the lunch meal that included: a low blood pressure, slurred speech, sluggishness, inability to carry on a conversation per his norm, inability to help in his care per his norm, and bloody urine in his catheter. [...]

Inspectors wroteBased on record review and staff interview the facility failed to assure they had provided training for all their staff on the facility's QAPI (Quality Assurance Performance Improvement) program.

Inspectors wroteBased on record review, resident interview, and staff interview the facility failed to ensure a resident's personal possessions were retained when her belongings were packed by staff when she was moved to a different room. This was for one (Resident # 4) of one sampled resident who had personal items packed away without the resident being present.

Inspectors wroteBased on record review, resident interview, staff interview, and pharmacy employee interview the facility failed to assure controlled substance records coincided with administration records for a controlled substance which a resident reported he did not receive as ordered. This was for one (Resident # 3) of two sampled residents reviewed for medications.

Inspectors wroteBased on record review, observation, resident, staff, pharmacy, paramedic, physician and the facility's Quality Assessment and Assurance (QAA) Committee interview, the facility's QAA failed to maintain implemented procedures and monitor interventions that the committee had previously put in place following the recertification and complaint investigation survey of 2/25/2022. This was for three recited deficiencies on the current complaint investigation survey of 12/8/2023. The deficiencies included: Notify of Changes (F580), Quality of Care/Professional Standards (F684), Pharmacy Services, Procedures, Pharmacist and Records (F755). The continued failure during two federal surveys of record showed a pattern of the facility's inability to sustain an effective Quality Assurance Program.

Inspectors wroteBased on record review, physician, and staff interviews, the facility failed to prevent an accident when Nurse Aide #2 performed a standing pivot transfer with Resident #11 instead of the care planned slide board transfer which caused her left leg to twist and resulted in a nondisplaced (not out of place) medial malleolus fracture (fracture of the inner bone of the ankle) and transversely oriented (bone broken perpendicular to its length). This was for 1 of 6 residents reviewed for accidents (Resident #11).

Inspectors wroteBased on observation and staff interviews, the facility failed to 1) label and date leftover food/drink items and clean the refrigerators/freezers in three of three nourishment rooms (nourishment room [ROOM NUMBER], #2 and #3) 2) allow meal trays to air dry prior to assemblage and stacking for two of two observations 3) clean the convection oven. These practices had the potential to affect all residents.

Inspectors wroteBased on record review and staff interview the facility ' s Quality Assessment and Assurance Committee failed to maintain implemented procedures and monitor interventions that the committee had previously put in place following the recertification and complaint survey of 02/25/22, revisit survey of 4/14/22, and complaint survey of 10/27/22. This was for 9 recited deficiencies in the areas of Quarterly Assessment At Least Every 3 Months (638), Accuracy of Assessments (641), Baseline Care Plan (655), Care Plan Timing and Revision (657), Bowel/Bladder Incontinence, Catheter, UTI (690), Label/Store Drugs & Biologicals (761), Resident Allergies, Preferences and Substitutes (806), Food Procurement, Store/Prepare/Serve - Sanitary (812), and Infection Prevention and Control (880). [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to implement an infection surveillance plan for monitoring and tracking infections in the facility. This practice had the potential to affect 97 of 97 residents in the facility. Findings Included: The facility's Infection Prevention and Control Program policy dated 1/2023 stated the Infection Preventionist (IP) was responsible for completing surveillance of healthcare associated infections, tracking outbreaks and monitoring standard and transmission precautions. During a meeting with the Infection Preventionist (IP) on 4/20/2023 at 3:45 p.m. the IP was unable to provide any documentation of tracking or surveillance of infections, infection risks or communicable disease outbreaks. [...]

Inspectors wroteBased on record review, staff interview and a Pharmacy Consultant interview, the facility failed to act on a pharmacy recommendation to draw a laboratory test on a monthly medication review written by the Consultant Pharmacist #1 for 1 of 6 residents reviewed for unnecessary medications (Resident #77).

Inspectors wroteBased on observation and staff interviews the facility failed to record an opened date on 3 of 4 insulin pens and failed to discard 1 of 1 expired insulin pens on 1 of 2 medication carts (700 Hall) observed for medication storage, failed to discard a tablet laying in the 100 hallway and left medications at the bedside for 2 of 2 residents who had not been assessed for safety of self-medication (Resident #33 and Resident #63).

Inspectors wroteBased on observation and staff interviews, the facility failed to maintain the area surrounding the dumpsters free of debris for 2 of 4 dumpsters observed.

Inspectors wroteBased on record review and staff interviews the facility failed to complete a quarterly Minimum Data Set (MDS) assessment within the required time frame for 1 of 25 residents reviewed for resident assessments (Resident #16).

Inspectors wroteBased on staff interviews and record review the facility failed to develop a baseline care plan including nutrition recommendations and provide a summary of the baseline care plan to residents or their representatives for 1 of 1 resident reviewed for baseline care plans (Resident #85).

Inspectors wroteBased on record review, resident representative interview and staff interviews, the facility failed to revise a care plan to include a physician's ordered intervention for 1 of 4 residents reviewed for dialysis (Resident #14) and to conduct a quarterly care plan meeting with the resident representative for 1 of 1 resident reviewed for care plan meetings (Resident #20).

Inspectors wroteBased on record review, staff interview, Nurse Practitioner interview, and physician interview, the facility failed to discontinue an antibiotic medication administered to treat a urinary tract infection (UTI) after the organism was identified as resistant to the medication on the laboratory report dated 02/24/23 for 1 of 3 residents reviewed for UTIs, Resident #32.

Inspectors wroteBased on record review, observation, resident interview, staff interviews and a dialysis center staff interview, the facility failed to provide 1 of 7 residents (Resident #14) reviewed for nutrition a breakfast meal and a snack before departure from the facility for a dialysis appointment.

Inspectors wroteBased on record review, staff interviews and physician interviews, the facility failed to discontinue an antibiotic medication as directed by the hospital emergency department because the identified organism in the urine culture was resistant to it for 1 of 5 residents reviewed for unnecessary medication administration, Resident #141.

Inspectors wroteBased on record review, staff interview and a Pharmacy Consultant #1 interview, the facility failed to ensure physician orders for an as needed (prn) psychotropic medication (a medication that affects the brain and mental processes) was time limited to a maximum duration of 14 days for 1 of 6 residents reviewed for unnecessary medications (Resident #77).

Inspectors wroteBased on observations, record review, resident and staff interviews, the facility failed to honor food preferences for 1 of 4 residents reviewed for food preferences (Resident #48).