Liberty Commons Rehabilitation Center

Inspectors wroteBased on record review and interviews with staff, Emergency Medical Services (EMS) personnel, and pest control specialist, the facility failed to ensure a resident's dignity was maintained when Resident #86 was observed by EMS personnel with multiple live cockroaches crawling on his body and in his bed prior to transferring the resident to the hospital. EMS personnel indicated the resident was not aware of the cockroaches. A reasonable person expects their dignity to be maintained by their caregivers and would have been traumatized and experienced feelings such as fear, dehumanization, humiliation, and anxiety. The deficient practice affected 1 of 2 residents (Resident #86) reviewed for dignity.

Inspectors wroteBased on observation, staff interviews, and record review, the facility failed to maintain a pest free environment for 3 of 3 residents reviewed for pest control (Resident #86, Resident #16 and Resident#5).

Inspectors wroteBased on observations and staff interviews, the facility failed to label and date opened food items in 1 of 1 walk in cooler and 1 of 1 walk-in freezer; failed to label, date, and discard expired food items stored on shelving in the kitchen; and failed to discard expired food items stored in 2 of 2 nourishment room refrigerators (100 and 300 hall nourishment rooms). This deficient practice had the potential to negatively affect the safety of food served to residents.

Inspectors wroteBased on record review, observation, and interviews with the Physician, Nurse Practitioner, resident, and staff, the facility failed to protect a cognitively intact female resident's (Resident #2) right to be free of sexual abuse when another female resident (Resident #1), who was cognitively impaired entered Resident #2's room and got into the bed with Resident #2 on 2/25/25 at 6:19 am. While in the bed Resident #1 kissed Resident #2 on the face, touched Resident #1's breasts and placed her hand inside the front of Resident #2's brief and attempted to touch her vagina. Resident #2 yelled out and Resident #1 got out of the bed and left the room. Resident #2 stated she was scared at the time and was still upset that it happened but was no longer afraid. Resident #2 was initially afraid until she learned that it was Resident #1 in her bed and not a man. [...]

Inspectors wroteBased on record review, staff, Physician, and the Consultant Pharmacist interviews the facility failed to prevent significant medication errors by administering Resident #223 the incorrect dose of a blood pressure medication, Losartan 50 milligrams (an antihypertensive), and administering blood pressure medications without following the physician's ordered parameters to hold the medication (Residents #223 and #47). This resulted in Resident #223 experiencing hypotension (low blood pressure) and symptoms of head pressure, neck pain, and nausea. There was no significant outcome for Resident #47. This deficient practice occurred for 2 of 2 residents reviewed for medication administration. Findings Included. 1.) Resident #223 was admitted to the facility on [DATE] with diagnoses including hypertension. [...]

Inspectors wroteBased on observations, record review, staff and the Nurse Practitioner interviews, the facility failed to comprehensively and effectively assess a resident's skin resulting in a delay in identifying and addressing a large, excoriated area (superficial wound or raw irritated patches with visible marks often caused by scratching, rubbing, or other mechanical trauma) behind the left knee of an immobile resident (Resident #25). The resident had a history of yeast developing in the folds of her skin. This deficient practice occurred for 1 of 1 resident reviewed for non-pressure related skin conditions.

Inspectors wroteBased on observations and staff interviews the facility, 1a) failed to remove black greenish substance from the commode base caulking in resident rooms (106,112, 214, 220, 303, and 410), 1b) failed to replace resident's missing florescent overbed light covers in rooms (201A, 201B, 203A, 203B, 207A, 207B, 208A, 208B, 212A, 212B, 214A, 214B, and 215B). These failures occurred on 4 of 4 hallways (100, 200, 300, and 400 Hall) observed for a safe, clean, homelike environment.

Inspectors wroteBased on record review and staff and resident interviews the facility failed to notify the nurse when a resident refused to be transferred with a mechanical lift and two nurse aides decided to transfer the resident (Resident #2) by manually lifting the resident from the bed to the shower bed causing her to fracture her tibia for 1 of 4 residents reviewed for accidents.

Inspectors wroteBased on record review and staff and resident interviews, the facility failed to resolve repeat grievances that were reported to the resident council meetings for 3 of 3 months that resident council meetings were held (June 2023, July 2023, and September 2023).

Inspectors wroteBased on observation, record review, resident and staff interviews, the facility failed to ensure food was palatable for 6 of 6 residents (Resident #66, Resident #9, Resident #15, Resident # 45, Resident #55, Resident #30) reviewed for food palatability.

Inspectors wrote2. a) Resident #332 was admitted to the facility on [DATE]. MDS assessment revealed Resident #332 was moderately impaired. An interview was conducted on 11/01/23 at 8:20 AM with Dietary [NAME] #3. When asked about evening snacks, who offered or prepared them, and which halls received them, the cook said he was not sure about snacks and who provided them. He said as far as he knew the kitchen staff did not provide evening snacks to the nurses for residents who were diabetics. An interview was conducted on 11/01/23 at 11:40 AM with Nurse #3. Nurse #3 stated the meals were always delivered late, with an example of 10/30/23 dinner trays arriving on the 300 and 400 halls close to 8:00 PM. The nurse said up to that point she had been passing out crackers to hungry residents right and left. [...]

Inspectors wroteBased on observation and staff interviews the facility failed to clean 1 of 3 ice machines used to provide ice for residents (300-400 hall ice machine).

Inspectors wroteBased on record review, observations and staff interviews the facility's Quality Assessment and Assurance (QAA) program failed to maintain implemented procedures and monitor interventions the committee put in place following the recertification and complaint investigation survey completed on 7/15/22 and the recertification survey completed on 05/03/21. This was for three repeat deficiencies originally cited in the areas of accuracy of assessments (F641), Label/Store Drugs and Biologicals (F761), and Food Procurement, Store/Prepare/Serve - Sanitary (F812). The continued failure during two or more federal surveys of record shows a pattern of the facility's inability to sustain an effective QA program.

Inspectors wroteBased on record review and the Administrator's interview, the facility failed to prevent a staff member from taking personal property from a resident's room (Resident #85) for 1 of 1 residents reviewed for misappropriation of property.

Inspectors wroteBased on record review and staff interviews, the facility failed to code the Minimum Data Set (MDS) assessments accurately in the areas of 1) nutritional status (Resident #66), 2) skin conditions (Resident #88), and 3) urinary continence (Resident #86) for 3 of 26 residents whose MDS assessments were reviewed.

Inspectors wroteBased on observation and staff interview the facility failed to discard expired bottles of medication that were stored in the Rehab medication cart for 1 of 3 medication carts inspected.

Inspectors wroteBased on staff interviews, Hospice staff interviews and record review the facility failed to maintain communication and coordination of services provided by Hospice in the medical record for 1 of 1 resident reviewed for Hospice services (Resident #70).