Liberty Care & Rehabilitation Center

Based on observation, interview, and facility policy review, the facility failed to maintain 1 (south side nourishment room refrigerator) of 2 nourishment room refrigerators in a clean and sanitary manner.Findings included: A facility policy titled, Equipment, revised 09/2017, indicated, All foodservice equipment will be clean, sanitary, and in proper working order. The policy specified, 4. All non-food contact equipment will be clean and free of debris. During an observation of the south side nourishment room on 07/07/2025 at 1:13 PM , the ice machine was noted to be dirty and had a pink and black substance on the interior ice deflector shield. The refrigerator had a dried, sticky dark brown liquid substance that had dripped down the interior back wall of the refrigerator. The bottom left drawer of the refrigerator had a dried, sticky, yellow substance in it. There was an unlabeled black lunch box that contained a dried white substance and an empty carton of milk that was stuck to dried white substance in the lunch box. During an observation of the south side nourishment room on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure 1 (Resident #34) of 5 sampled residents reviewed for unnecessary medications was assessed for self-administration of medication.Findings included: A facility policy titled, Medication Administration Self-Administration by Resident, dated 01/2023, indicated, Residents who desire to self-administer medications are permitted to do so with a prescriber's order and if the nursing care center's interdisciplinary team has determined that the practice would be safe and the medications are appropriate and safe for self-administration. A Resident Face Sheet indicated the facility admitted Resident #34 on 01/10/2023. According to the Resident Face Sheet, the resident had a medical history that included diagnoses of chronic obstructive pulmonary disease (COPD) and acute and respiratory failure with hypoxia. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/12/2025, revealed Resident #34 had a Brief Interview for Mental Status (BIMS) score of 15, which…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of the facility's documents and policies, the facility failed to provide a clean and homelike environment for residents. Observations on 06/10/2024 and 06/11/2024, revealed the facility failed to ensure the interior of the building including residents' room walls and residents' room doors were in good repair. The observations revealed peeling paint or missing paint on the walls and some areas had wood missing from the doors leaving rough edges or gouges. Additionally, residents' rooms and bathrooms had a strong odor of urine. This affected the rooms and/or bathrooms for rooms 216, 217, 218, 219, 220, 221, 222, 223, 224, 225, and 226. Additionally, the shared bathroom between rooms [ROOM NUMBERS] had two (2) open urinals containing urine, hung on the handrail which were not bagged. One (1) of the urinals was not labeled for identification. The findings include: Review of the facility's policy titled, Resident Rights, revised March 2017, revealed the resident had a right…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, review of the Manufacturer's Instructions for use of the Assure Platinum Blood Glucose Monitoring System and review of the facility's policies, the facility failed to develop and implement an ongoing infection prevention and control program (IPCP) to prevent, recognize, and control the onset and spread of infection to the extent possible. The facility failed to develop a water management program based on nationally accepted standards, specific to their building description, in order to prevent, detect and control water-borne contaminants and reduce Legionella growth. This had the potential to affect the entire population of the facility. Observation of a fingersick revealed staff failed to clean the glucometer according to facility policy and the Manufacturer's Instructions. Observation of medication pass revealed that staff failed to clean the shared blood pressure cuff and the shared pulse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record review, and review of the facility's policy, the facility failed to make the appropriate Level II Preadmission Screening and Resident Review (PASARR) referral based on the positive Level 1 PASARR screening results for one (1) of two (2) sampled residents reviewed for PASARR Screening (Resident (R)19) out of a total sample of forty-two residents. The facility assessed R19 to have a positive Level I PASARR screen at admission on [DATE]. This screening indicated the resident required a Level II Screening; however, the facility failed to ensure a Level II Screening was completed in the required timeframe. The findings include: Review of the facility's policy titled, Pre-admission Screening and Resident Review (PASARR), revised 09/15/2023, revealed a positive Level I screen necessitates an in-depth evaluation of the individual by the state-designated authority, known as PASARR Level II, which must be conducted prior to admission to a nursing facility. PASARR Level II is a comprehensive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming, and personal and oral hygiene for two (2) of 42 sampled residents, Resident #55 and #55 (R55 and R58). R55 complained on 06/12/2024, staff had not brushed her teeth or swabbed her mouth, and she did not receive assistance with mouth care very often. R55 further complained she was given a bed bath twice a week and her privates were washed only when she had a bowel movement. Additionally, observation of R58, on 06/10/2024 and 06/11/2024, revealed his fingernails were long and dirty and he had not been shaved. R58 was wearing the same dark gray shirt both days. The findings include: Review of the facility's policy titled, Activities of Daily Living (ADLs), created on 09/15/2023, revealed ADL assistance would be provided on a level appropriate to the resident's level of functioning and learning and/or the responsible party's level of support…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and review of the facility's policy, the facility failed to ensure residents requiring respiratory care received care consistent with professional standards of practice for one (1) resident reviewed for respiratory care out of a total of 42 sampled residents, Resident #58 (R58). Observation on 06/10/2024 and 06/11/2024, revealed R58 was receiving oxygen at two (2) liters per minute per nasal cannula as per Physician's Orders. However, the oxygen tubing was not dated. The findings include: Review of the facility's policy titled, Oxygen Administration Policy, revised 05/30/2024, revealed oxygen tubing was to be changed monthly or as needed. Review of R58's electronic medical record (EMR) Face Sheet, revealed the facility admitted the resident on 05/06/2024 with diagnoses including congestive heart failure, dementia, benign prostatic hyperplasia, and atherosclerotic heart disease. Review of R58's admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/13/2024, revealed the resident required continuous oxygen therapy. Review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, record review, and review of facility policy, the facility failed to have prescribed medications available to administer for one (1) of 42 sampled residents, Resident #332 (R322). R322's Physician's Orders, dated 06/07/2024, untimed, revealed orders for rifampin 300 milligrams (mg), two (2) tablets, to be administered daily between 7:00 AM and 11:00 AM. However, the medication was not delivered to the facility until 06/10/2024 at 8:15 PM, four (4) days after it was ordered. Refer to F761. The findings include: Review of the facility's policy titled, Medication Administration, General Guidelines, revealed medications were to be prepared only by licensed medical or pharmacy personnel authorized by state regulations to prepare medicine. Review of R322's electronic medical record (EMR) Face Sheet revealed the facility admitted the resident on 06/07/2024 with a diagnosis of latent tuberculosis (TB). Review of R322's Physician's Orders, dated 06/07/2024, untimed, revealed orders for rifampin 300 milligrams (mg), two (2) tablets, to be administered daily between 7:00 AM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure residents were free of significant medication errors for one (1) of 42 sampled residents, Resident 332 (R322). On 06/07/2024, R322 was prescribed two (2), 300 milligram (mg) tablets of rifampin (antibiotic to treat Tuberculosis) to be given once daily. However, R322 received half the dose (1 table, 300 mg) on 06/11/2024, and 06/12/2024. The findings include: Review of the facility's policy titled, Medication Administration General Guidelines, revealed medications were to be administered in accordance with written orders of the prescriber. Further review revealed those giving a medication should verify the medication is correct three (3) times before administering: when pulling the medication package from the medication cart, when the dose was prepared, and before the dose was administered. Review of R322's electronic medical record (EMR) Face Sheet revealed the facility admitted the resident on 06/07/2024 with a diagnosis of latent tuberculosis (TB). Review of R322's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of the facility's policy, the facility failed to ensure drugs and biological's used in the facility were labeled, dated, and stored in accordance with currently accepted professional principles for one (1) of four (4) medication carts. Observation of the North Wing's A-C Medication Cart, on [DATE] at 10:15 AM, revealed two (2) opened vials of Insulin Glargine U100 with no opened date. The findings include: Review of the facility's policy titled, Medication Storage, dated 2007, revealed the purpose of the policy was to ensure medications and biological's were stored properly, following the manufacturer's or the provider's pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. Per the policy, medications should remain in packaging provided by the pharmacy. Observation of the North Wing's A-C Medication Cart, on [DATE] at 10:15 AM, revealed two (2) opened vials of Insulin Glargine U100 which were not marked with the opened…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY The facility failed to ensure implementation of the comprehensive care plan for two (2) of twenty (20) sampled residents (Residents #6 and #78). The care plan for Residents #6 and #78 required staff to ensure the resident's urinary catheter bag was covered. However, observations of the residents revealed the residents did not have urinary catheter drainage bag privacy/dignity covers as was care planned for each resident. The findings include: Review of the facility's Comprehensive Care Plan Policy, revised 07/19/18, revealed care plan interventions were implemented after consideration for the resident's problem areas and their causes. The policy further revealed the interventions would reflect the action, treatment, or procedure to meet the objectives toward achieving the resident's goals. 1. Review of Resident #78's medical record revealed the facility admitted the resident on 03/14/16 with diagnoses of Hypertension, Obstructive Uropathy, Dementia without behaviors, Parkinson's disease, and Depression. Review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.