Liberty Community Living Ctr

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure food items were stored, dated, and maintained in accordance with professional food safety standards for one (1) of three (3) kitchen observations.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide an ongoing program of individualized activities to meet the physical, mental, and psychosocial needs of residents residing on the Dementia Unit for two (2) of two (2) sampled residents reviewed on the Alzheimer's Unit (Residents #9 and #63), with the potential to affect all nineteen (19) residents on the unit.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility's Quality Assurance and Performance Improvement (QAPI) Committee failed to sustain corrective actions to prevent recurrence of a previously cited deficiency, specifically, the facility was cited for failing to store food in accordance with professional standards for food service safety related to food items not dated, exposed foods, and expired foods during an annual recertification survey on 8/22/24 and was cited again for the same deficiency during the current survey, demonstrating that QAPI failed to sustain ongoing monitoring and oversight to prevent recurrence for one (1) of ten (10) deficiencies cited.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure a resident's right to be free from invasion of personal privacy when the Administrator took and shared photographs of the resident without his consent for one (1) of 19 sampled residents. Resident #10 Findings Include:A review of facility's Residents Rights and Qualify of Life Policy and Procedure, undated, revealed, .All residents have the right to a dignified existence, self-determination and communication and access to people and services inside and outside the facility .A record review of the admission Record revealed the facility admitted Resident #10 on 10/12/25, with diagnoses including Quadriplegia. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to implement care plan interventions related to oral hygiene (Resident #57) and Percutaneous Endoscopic Gastrostomy (PEG) care (Resident #70) for two (2) of 19 sampled residents. Findings Include:A review of the facility's Care Plan Policy and Procedure, undated, revealed, .Each resident's care plan will remain current and inform staff of resident's needs. Resident #57A record review of the admission Record revealed the facility admitted Resident #57 on 2/14/25 with diagnoses including Need for Assistance with Personal Care. A record review of the Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 11/20/25 revealed Resident #57 had a Brief Interview for Mental Status (BIMS) score of 6, which indicated her cognition was severely impaired. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure Activities of Daily Living (ADL) care, including oral hygiene was provided for one (1) of one resident who required staff assistance with oral care, Resident #57.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to provide care and services in a manner to prevent complications for one (1) of three (3) residents reviewed for tube feeding and nutrition, Resident #70.

Inspectors wroteLevel IIBased on observation, interview, record review, and facility policy review, the facility failed to ensure medications and biologicals were securely stored and properly labeled when a controlled substance returned by a resident was left unlabeled on a medication cart and when a wound care cart containing treatment chemicals was unlocked and accessible to residents for two (2) of three (3) medication/treatment carts reviewed. Findings Include:A review of the facility's Medication Storage Policy and Procedure, undated, revealed, .Policy: 1. Medications and biologicals will be maintained in a secured location only accessible to designated staff. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received a diet and follow-up dental care consistent with the resident's nutritional needs and edentulous status when the resident remained without dentures for over two (2) months and continued to receive regular-texture meals for one (1) of nineteen (19) sampled residents (Resident #76). Findings Include:On 12/01/2025 at 1:50 PM, in an interview, Resident #76 stated his teeth had been lost in the laundry. The facility had taken him to a dentist about a month ago for a fitting, but he had not heard anything further about replacement dentures. On 12/03/2025 at 12:35 PM, an interview and observation of Resident #76 revealed he had a lunch tray consisting of fried chicken, green beans, mashed potatoes, and cornbread. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to implement appropriate infection prevention and control practices during indwelling catheter care (Resident #6), and failed to follow hand hygiene, glove-use, surface sanitation, and Enhanced Barrier Precautions (EBP) requirements during enteral feeding tube care (Resident #70) for two (2) of three (3) residents reviewed for care.

Inspectors wroteBased on interviews, record reviews, and facility policy review, the facility failed to employ proper bookkeeping techniques and prevent the commingling of resident funds for one (1) of four (4) residents reviewed with the potential to affect any residents who have or have had a resident trust fund.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure residents were free from misappropriation of funds for one (1) of four (4) residents reviewed (Resident #3), with the potential to affect 53 residents who have a resident trust fund.

Inspectors wroteBased on observation, interviews, record reviews, and facility policy review, the facility failed to report allegations of misappropriation of resident property within 24 hours of notification of the allegation to the State Agency (SA) and local authorities for one (1) of four (4) residents reviewed with trust accounts.

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to thoroughly investigate an allegation of misappropriation of resident property for one (1) of four (4) residents reviewed with trust fund accounts. Resident #3.

Inspectors wroteBased on observation, interviews, and facility policy review, the facility failed to store food in accordance with professional standards for food service safety related to food items not dated, exposed foods, and expired foods in one (1) of two (2) kitchen observations. Findings Include: A review of the facility's policy titled Labeling and Dating for Safe Storage of Food, revised 03/06/2020, revealed .All products should be dated when opened . Use Use-By dates on all food once opened . When food is taken out of an original container . write . the Use-By date . The facility did not provide a policy that specifically addressed exposed food products. On 8/19/14 at 10:31 AM, an observation of the kitchen revealed Refrigerator #1, revealed the following: one (1) 46-ounce carton of orange juice with an open on date of 4/11/24 and a manufacturer's best if used by date of [DATE]; [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to assist a resident with eating in a dignified manner during a dining observation, as evidenced by a Certified Nurse Aide (CNA) was observed standing over a resident while assisting the resident to eat during one (1) of two (2) meal observations. Resident #21 Findings Include: A review of the facility's policy titled Resident Rights, revised and implemented 11/28/16, revealed, .The resident has a right to a dignified existence .A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident . [...]

Inspectors wroteBased on record review, staff interviews, and facility policy review the facility failed to provide the Notice of Medicare Non-Coverage letter indicating the resident was notified prior to Medicare coverage ending for two (2) of three (3) residents reviewed for beneficiary protection notification. (Resident #12 and Resident #34) Findings Include: Review of the facility's policy titled, Medicare Advanced Beneficiary Notice, with a review date of 7/24/23, revealed Residents are informed in advance when changes will occur in their bills. [...]

Inspectors wroteBased on observations and staff interviews, the facility failed to store and date respiratory equipment in a manner that prevented possible cross-contamination and consistent with professional standards of practice, as evidenced by, undated tubing and a face mask not being bagged when not in use, for two (2) of four (4) observations. Resident #171. Findings Include: A record review of the facility's Oxygen Administration policy, dated August 25, 2014, revealed Purpose: The purpose of the procedure was to provide guidelines for safe oxygen administration . The policy did not address handling and storage of oxygen tubing. On 08/19/24 at 11:41 AM, an observation of Resident #171 revealed that the oxygen tubing attached to the resident was not dated, and the face mask, which was not in use, was hanging from the wall and not placed in a bag. [...]

Inspectors wroteBased on observations, interviews and facility policy review the facility failed to prevent the potential for the spread of infection as evidenced by, facility staff observed transporting linen in an unsanitary manner for two (2) of six (6) hall observations. Findings Include: Review of the facility's policy titled, Departmental (Environment Services) - Laundry and Linen, revised August 2009, revealed .The purpose of this procedure is to provide a process for the safe and aseptic handling, washing and storage of linen . In Resident Rooms 1. Do not allow linen clean or soiled to touch clothing or uniform. 2. Handle all linen as though it is potentially infectious . On 08/21/24 at 10:20 AM, an observation of Certified Nursing Assistant (CNA) #2 revealed the CNA hugging clean linen to her uniform going down the 400 hall and placing it on the laundry cart in the hallway. [...]

Inspectors wroteBased on record review and interviews, the facility failed to provide safe, functional transportation that ensured a reasonably comfortable environment for residents during transport for one (1) of 21 sampled residents. Resident #52 Findings Include: During an interview on 08/19/24 at 11:14 AM, Resident #52 revealed that on 08/12/2024, he was transported two hours away from the facility in a transport van that did not have functioning air conditioning. He stated that during the morning transport, it was hot and stuffy, but not as bad as the afternoon ride back to the facility. He described the van as having no real windows in the back that could open, only two small vents that did not allow much air to circulate, making the trip very uncomfortable. As a quadriplegic, he was unable to fan himself, which added to his discomfort. [...]

Inspectors wroteBased on interviews, record review, and policy review, the facility failed to provide adequate supervision to prevent a cognitively impaired resident from exiting the facility unnoticed and unsupervised through a remotely opened front door for one (1) of three (3) residents reviewed. Resident #1 Resident #1 was able to exit the front door when the door was opened remotely by staff to allow visitors to enter the facility at approximately 2:49 PM on 6/29/24. The facility staff were unaware of Resident's absence until approximately 3:00 PM, when the family member of another resident called the facility to report they saw the resident beside a two-lane highway, approximately 0.44 miles from the facility. The facility staff located the resident at approximately 3:02 PM, at the described location and the resident was returned to the facility, without incident. [...]

Inspectors wroteBased on observation, facility policy review, and interviews, the facility failed to implement an ongoing resident centered activities program that engages the residents in meaningful activities that are individualized and customized for 13 of the 13 residents on the Memory Care Unit.

Inspectors wroteBased on observation, interviews, record reviews, and facility policy review, the facility failed to ensure that the facility's designated Hospice Coordinator coordinated care that was provided by the hospice service and the facility for one (1) of one (1) sampled hospice residents.