Liberty Commons Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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). Findings included:Resident # 86 was admitted on [DATE].A review of Resident #86's admission Minimum Data Set (MDS) dated [DATE] revealed the resident had moderate cognitive impairment with no behaviors, required a wheelchair for mobility and supervision with bathing and dressing. A review of the pest control company's invoices from December showed that weekly services were provided. The invoices dated December 3 and December 17, 2025, indicated that rooms on the 100 and 200 halls were treated with an aerosol product; however, they did not document the reason for the treatment or provide details about the specific application. The invoice dated December 24, 2025, noted evidence of German cockroaches in room [ROOM NUMBER]. The invoices did not include documentation of staff reports regarding cockroach activity,…

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 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.Findings included:a. An initial tour of the kitchen was conducted on 3/9/26 at 10:50 AM in the presence of the Dietary Manager.- At 10:50 AM on 3/9/26 an opened plastic bag containing hard boiled eggs was observed in the kitchen walk in cooler undated.- At 10:55 AM on 3/9/26 an opened undated plastic bag of breadsticks and an opened plastic bag of shredded cheese with an opened date of 1/9/26 was observed in the walk-in freezer.An interview conducted with the Dietary Manager on 3/9/26 at 11:00 AM revealed that all food items were expected to be labeled and dated upon opening, and any expired items were to be discarded.…

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 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. The deficient practice occurred for 1 of 5 residents reviewed for abuse (Resident #2). The findings included: Resident #1 was admitted to the facility on [DATE]…

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 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. Findings included. Resident #25 was admitted to the facility on [DATE]. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #25 was cognitively intact. She exhibited no behaviors and had no rejection of care. She required extensive two-person assistance with activities of daily living. Her weight was 240 pounds. A care plan revised 12/19/24 revealed Resident #25 had the potential for impaired…

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 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). Findings included: The June 21, 2023, meeting minutes recorded by the Activity Director indicated concerns were expressed with dietary. The Resident Council stated meals were up to an hour late, were cold when received, and the food was overcooked and hard to chew. The June Grievance log listed no grievance dated 6/21/23 on behalf of the Resident Council related to the concerns expressed at the meeting regarding late meals, cold food and food that was overcooked and hard to chew. The July 31, 2023, meeting minutes recorded by the Activity Director indicated concerns were expressed with dietary. The Resident Council indicated meals were up to an hour late and were cold when received. Meals were served on Styrofoam trays instead of proper dinnerware. The council requested to meet with the Dietary Manager as soon as possible.…

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, 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. Findings included: a). Resident #66 was admitted to the facility on [DATE]. Review of Resident #66's 9/26/23 annual Minimum Data Set (MDS) indicated resident was cognitively intact. Interview on 10/30/23 at 11:53 AM with Resident #66 revealed the food was usually cold, he often could not tell what the meals were, and the food usually did not taste good A follow up interview with Resident #66 on 10/31/23 at 5:45 PM, Resident #66 stated it was frustrating when the food was not palatable. b). Resident #9 was admitted to the facility on [DATE]. Review of Resident #9 ' s 9/18/23 quarterly MDS assessment indicated resident was cognitively intact. Interview with Resident #9 on 10/30/23 at 12:21 PM revealed the food was not prepared good and the meals did not look or…

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 2. 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. She said the 300 and 400 halls did not offer or provide diabetic residents with specific labeled evening snacks. An interview was conducted on 11/01/23 at 11:45 AM with Medication Technician (MT) #1. She said they did not offer or…

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 and staff interviews the facility failed to clean 1 of 3 ice machines used to provide ice for residents (300-400 hall ice machine). The findings include: An observation of an ice machine on 11/02/23 at 11:30 AM located in the nutrition room on the 300-400 hall revealed a black tinged substance located on the silver galvanized linear plate located inside the machine over the ice. This black substance was observed by the Maintenance Director. An interview was conducted on 11/02/23 at 11:35 AM with the Maintenance Director. The Maintenance Director stated the ice machine was last serviced and cleaned by their vendor on 07/18/23. He said nursing staff were supposed to clean out and wipe down the ice machine monthly and sign off on a log that the ice machine was wiped-out and cleaned, which they did not do. The Maintenance Director stated the ice machine needed to be consistently cleaned and sanitized to prevent mold or water borne pathogens from developing. The Maintenance Director stated the blackened substance he observed should not have been present inside the…

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 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. Findings included: This tag is cross-referenced to: F641: Based 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. During the…

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 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. Findings included: Resident #85 was admitted to the facility on [DATE] and discharged on 08/23/23. Admitting diagnoses included, in part, non-displaced fracture of left radius and fracture of nasal bones. The Minimum Data Set admission assessment dated [DATE] revealed Resident #85 was cognitively intact. Resident #85's hearing and vision were adequate and he required limited assistance with one staff physical assistance with activities of daily living. An initial allegation report dated 08/07/23 was completed by the Administrator. The incident type was misappropriation of property. The facility became aware of the misappropriation of Resident #85's missing wallet at 1:45 PM. A summary of the allegation revealed Resident #85 stated a man came in his room and the resident woke up to…

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 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. Findings included: 1). Resident #66 was admitted to the facility on [DATE] with diagnosis which included in part: stroke with hemiparesis, dysphagia (swallowing difficulty), congestive heart failure, and diabetes. Review of Resident #66's electronic health record revealed a 1/28/22 physician order for low concentrated sweets diet regular texture with thin consistency liquids. Review of Resident #66's progress notes revealed a 8/16/23 registered dietician note, which indicated resident received a low concentrated sweets diet with double portions and had significant weight gain in the past 180 days. Review of Resident #66's weight summary indicated: 9/22/2023 210.0 8/2/2023 205.2 7/13/2023 201.0 6/1/2023…

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 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. Findings included: The Rehab medication cart was inspected on 11/02/23 at 9:25 AM with the Director of Nursing present and was found to have the following expired medications on the cart: 1. [NAME]-Vite supplement that had expired 10/23. 2. Sodium Chloride 1 gram that had expired 9/23. 3. Aspirin 325mg that had expired 10/23. 4. Travel Ease Meclizine 25mg that had expired 9/23. 5. Gas Relief 180 mg (Smethicone) that had expired 9/23. 6. Zinc 50 mg that had expired 10/23. In an interview with the Director of Nursing on 11/02/23 at 9:30 AM she stated the cart had been inspected on 10/30/23 by a Medication Tech and nurse. She had expected any expired medications to be removed from the cart and destroyed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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). The findings included: Resident #70 was admitted to the facility on [DATE]. His diagnosis included cerebral infarction, hypertension, tachycardia, neurogenic bowel, and anemia. A Weekly Hospice note dated 08/04/23 for Resident #70 revealed Hospice Nurse (SN) visit for facility patient with diagnosis of hemiplegia following cerebral infarct affecting left side. Upon visit, the patient is in bed with head elevated. He is nonverbal and contracted in all extremities, with no signs or symptoms of pain or distress. He does blink and occasionally will track with his eyes when spoken to. He is frail and his skin is fragile and has an air mattress in use. Foam boots on feet. His trach is intact, with clear frothy sputum noted on gown, with tube feeding infusing, and his…

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.