Liberty Commons Nursing and Rehabilitation Center

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to discard expired medications stored for use and discard loose pills observed in 3 of 5 medication (med) carts (the 200 hall, 400 hall and 600 hall medication carts) and failed to discard expired medications stored in 2 of 3 medication storage rooms (100 hall and 300 hall) reviewed for medication storage.

Inspectors wroteBased on record review, and staff, Wound Physician, and Nurse Practitioner interviews, the facility failed to maintain accurate medical records by 1.) not documenting the administration of wound care to an unstageable sacral wound on the Treatment Administration Record (TAR) or in the electronic medical record and not accurately documenting the assessment of an implanted device (a device placed under the skin typically in the chest wall and used for long term intravenous (IV) access) for Resident #49. 2.) not accurately documenting that an antihypertensive medication (Hydralazine 25 milligrams) was held for systolic blood pressure less than 125 mmHg (millimeters of mercury) according to the physician orders (Resident #28). 3.) not accurately documenting the removal of a dressing from an arterial/venous (A/V) dialysis shunt (Resident #55). [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to code the Minimum Data Set (MDS) accurately in the areas of fluid intake per day by intravenous (IV) or tube feeding and the use of antipsychotic medication on a daily basis for 1 of 24 residents whose MDS assessments were reviewed (Residents #91).

Inspectors wroteBased on record review, and staff, Registered Dietitian and Nurse Practitioner interviews, the facility failed to address a Registered Dietitian recommendation to obtain weekly weights for 1 of 4 residents reviewed for nutrition (Resident # 75).

Inspectors wroteBased on observations, record review, and staff and Nurse Practitioner interviews, the facility failed to: remove an ordered pressure dressing to a newly inserted arterial/venous (A/V) dialysis shunt site 4-6 hours after the resident returned from dialysis, check the resident's arterial/venous dialysis shunt when resident returned from dialysis and clarify orders that were entered inaccurately. This was for 1 of 1 resident (Resident #55) reviewed for dialysis.

Inspectors wroteBased on record review and interviews with staff, Medical Director (MD) and Physician Assistant (PA), the facility failed to notify the physician when a resident had signs of Clostridium Difficile (C. difficile) that included persistent loose, watery, mushy, and odorous stool. From 2/9/24 through 2/27/24 the resident experienced these abnormal stools. The physician was notified on 2/13/24 of the abnormal stools, but was not made aware of the ongoing issue until 2/27/24 when it was brought to the nurse's attention by the resident's family member. Upon discharge from the facility on 2/28/2024, the resident was immediately transported by a family member directly to her Primary Care Physician's office where she was tested for C. Difficile, and the lab test was positive for C. Difficile on 2/29/2024. This deficient practice placed Resident #86 at risk for developing complications from C. [...]

Inspectors wroteBased on record review and family, staff, Medical Director, and Physician Assistant interviews, the facility failed to comprehensively assess a resident who was presenting with signs of Clostridium Difficile (C. difficile) (According to the Centers for Disease Control and Prevention (CDC): C. difficile-is a highly contagious bacteria that causes diarrhea and inflammation of the colon and can be life-threatening; symptoms include 3 or more foul smelling watery stools a day lasting longer than 1 day, and abdominal cramping), to determine the cause of the watery stools, identify the seriousness of the symptoms, and implement effective interventions to treat repeat watery stools which started on 2/09/2024. [...]

Inspectors wroteBased on record reviews and staff interview, the facility failed to schedule a Registered Nurse (RN) for at least 8 consecutive hours 12 of 122 days reviewed. The days included 06/10/23, 06/11/23, 06/24/23, 07/02/23, 07/09/23, 07/23/23, 10/29/23, 11/11/23, 11/12/23, 11/18/23, 11/19/23, and 11/26/23.

Inspectors wroteBased on record review, staff interviews, Pharmacist Consultant and Physician interviews the Pharmacy Consultant failed to identify that a resident (Resident #59) received 10 units of Novolog Insulin before meals for diabetes for an order to hold if glucose (blood sugar level) was less than 120 milligrams per deciliter (mg/dl) 10 times during two monthly drug regimen reviews (June 2024 and July 2024) for 1 of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on record review, staff interviews, Pharmacist Consultant and Physician interviews the facility failed follow a physician's order when a resident (Resident #59) received 10 units of Novolog Insulin before meals for diabetes when the order read to hold if glucose (blood sugar level) was less than 120 milligrams per deciliter (mg/dl). Resident received the medication 6 times between June 22, 2024, and July 24, 2024, for 1 of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on record review, observations and staff interviews, the facility failed to maintain infection control prevention by: (1) touching medications with bare hands during medication preparation for 1 of 3 medication administration observations completed; and (2) failed to follow enhanced barrier precautions while caring for a resident ' s feeding tube for 1 of 2 residents observed for tube feeding care (Resident #37 ). Finding Included: The facility policy for Medication Administration effective 12/2023 under Administration of Oral Medications reads: Never touch pills or tablets with bare hands. 1) During an observation of a medication administration pass on 07/23/24 at 8:46 am Medication Aide #4 was observed handling the following medications with her bare hands: Lasix, Protonix, Docusate, Carvedilol, Micro K, Preservision, and Zoloft. [...]

Inspectors wroteBased on record review, staff and the Senior Director of Compliance for the Orthopedic Office/Registered Nurse (RN) and Physician interviews, the facility failed to contact the Orthopedic office for clarification and instructions for removal of the orthopedic pneumatic (air pressure) boot, dressing changes and skin assessments on a resident's left ankle (Resident #7) after her follow-up appointment with the physician's assistant on 12/21/2023. Resident #7 developed deep tissue injuries (DTI) to the bottom of her left great toe, left lateral foot and left heel. This was for 1 of 3 residents reviewed for pressure ulcers.

Inspectors wroteBased on record review, observations, staff and Physician interviews, the facility failed to provide incontinence care safely for a resident who was dependent on staff assistance for 1 of 4 residents reviewed for falls (Resident #1). On 1/2/24 Nurse Aide (NA) #6 was attempting to pull the brief out from under Resident #1 by turning him onto his side and pressing on his back for him to roll over resulting in the resident rolling off the side of the bed and landing on the floor on his left shoulder and neck. Resident #1 experienced pain on the left side of his neck at a level of 8 out of 10 (with 10 being the worst pain possible), cervicogenic headaches (a pain that develops in the neck and is felt in the head), and sustained a cervical neck strain of the left trapezius muscle (injury to the large muscle in the back that supports the head and neck caused from overstretching or trauma).

Inspectors wroteBased on observations, record review, and staff, resident and Physician interviews the facility's Quality Assurance and Performance Improvement (QAPI) Program failed to maintain implemented procedures and effective monitoring of interventions the committee put into place following the recertification and complaint investigation survey of 5/4/2023 and the complaint investigation survey of 9/15/23. This was for one recited deficiency in the area of supervision to prevent accidents (F689). During the 5/4/2023 recertification and complaint investigation survey, deficient practice was cited for failing to provide incontinence care safely to a dependent resident when the resident fell off the bed during care and fractured her right femur (thighbone) in two places. [...]

Inspectors wroteBased on observation, record review, staff, and Nurse Practitioner (NP) interviews, the facility failed to assess, monitor, document progress, and provide treatment for an open wound (skin tear) on the top of Resident #11's right foot for 1 of 5 residents reviewed for skin concerns. Weekly skin checks did not include the existence of a dressing to the right foot from the end of November 2023 through the end of February 2024. Observation on 2/27/24 revealed a dressing dated 11/17 on the top of the right foot. Once the dressing was removed from the top of the right foot, a wound with a dark hard perimeter and a soft yellow center was noted.

Inspectors wroteBased on record review, staff and resident interviews, the facility administration failed to provide effective leadership and oversight to ensure residents were protected from potential misappropriation of property by having no system in place to account for purchases made by staff for residents with resident funds, credit cards, debit cards or Electronic Benefit Transfer (EBT) card. This failure affected 1 of 3 residents reviewed for misappropriation of property and had the potential to affect other facility residents.

Inspectors wroteBased on record review, observations, staff and Physician interviews, the facility failed to provide a bed bath safely for a dependent resident for residents reviewed for falls. Resident #2 sustained a fall off the bed during care, fracturing her left femur (thighbone) and tibia (shinbone) for 1 of 2 residents reviewed for falls (Resident #2).

Inspectors wroteBased on record review, observations, and staff and physician interviews, the facility's Quality Assurance and Performance Improvement (QAPI) Program failed to maintain implemented procedures and effective monitoring of interventions the committee put into place following the recertification and complaint investigation survey of 5/4/23. This was for one recited deficiency in the area of supervision to prevent accidents (F689). During the 5/4/23 survey, deficient practice was cited for failing to provide incontinence care safely to a dependent resident when the resident fell off the bed during care and fractured her right femur (thighbone) in two places. [...]

Inspectors wroteBased on record review, observations, staff and Physician interviews, the facility failed to provide incontinence care safely for a dependent resident (Resident #59) for 1 of 2 residents reviewed for falls. Resident #59 rolled off the bed during care, fracturing her right femur in two places.

Inspectors wroteBased on record review and staff interview the facility failed to complete comprehensive assessments within the 14-day required timeframe for 7 of 19 residents (Resident #82, Resident #32, Resident #75, Resident #81, Resident #71, Resident #28 and Resident #37) reviewed for comprehensive Minimum Data Set (MDS) assessments.

Inspectors wroteBased on observations, record review and staff interviews the facility failed to follow the manufacturer's guidelines to discard oral inhaler vial solutions after one week of being exposed to light and to record an opened date on the package (100 hall cart), failed to secure and label loose pills (100, 200 and 400 hall carts), failed to record an opened date on two insulin (medication to treat diabetes) pens (200 hall cart), failed to store the correct resident's insulin pens in the assigned storage devices for Resident #28 and #68 (200 hall cart), failed to discard expired medication (400 hall cart), and failed to keep unattended medications in a locked medication cart (100 hall cart). These observations were for 3 of 6 medication carts observed for medication storage.

Inspectors wroteBased on record review, observations and staff interviews the facility failed to remove expired and spoiled food items stored for use in the walk-in refrigerator and failed to label, date leftover food and remove expired food items for 1 of 2 nourishment rooms observed (400 Hall nourishment room). This practice had the potential to affect the food served to the residents.

Inspectors wroteBased on observations, record review and staff and resident interviews, the facility's Quality Assurance and Performance Improvement Program (QAPI) failed to maintain implemented procedures and monitor interventions that the committee put into place following the focused infection control and complaint investigation survey of 12/10/20 and a recertification and complaint investigation survey of 4/5/22. This was for 3 recited deficiencies on the current recertification and complaint investigation survey of 5/4/23 in the areas of resident assessments (F641), label/store drugs and biologicals (F761) and food storage (F812). The continued failure during two or more federal surveys of record shows a pattern of the facility's inability to sustain an effective Quality Assurance program.

Inspectors wroteBased on record review and staff interviews, the facility failed to complete quarterly assessments within the required 14-day timeframe for 5 of 19 residents reviewed for Minimum Data Set (MDS) assessments (Resident #45, Resident #59, Resident #41, Resident #62, and Resident #60).

Inspectors wroteBased on record review, resident and staff interviews, and observation the facility failed to code the Minimum Data Set (MDS) assessment accurately in the areas of 1.) bed rails (Resident #59); 2). vision and hearing (Resident #41) and 3). tobacco use (Resident #60) for 3 of 19 residents reviewed for accuracy of MDS assessments.

Inspectors wroteBased on record review and staff interviews the facility failed to develop a comprehensive person-centered care plan in the areas of 1.) bed rails (Resident #59) and 2.) hearing loss (Resident #41) for 2 of 19 residents reviewed for comprehensive care plans.

Inspectors wroteBased on observations, record review and staff interviews the facility failed to record the correct resident census (number of residents in a certified bed) for 18 out 18 daily nursing staff posting forms reviewed.