Liberty Health Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for one of nine residents (Resident #2) reviewed for pharmacy services. The facility failed to ensure Resident #2 took her morning medications and the medications were not left in her room, unsecured, on her bedside table on 02/10/26. This deficient practice could place residents at risk of not being monitored for their medications, adverse reactions, and drug diversion.Findings included: Record review of Resident #2's face sheet, dated 01/11/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #2 had diagnoses which included delusional disorder (a type of serious mental illness characterized by holding one or more firm, false beliefs) and schizophrenia (mental health condition that affects…

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 record review, the facility failed to ensure residents had the right to be free from misappropriation of property and exploitation for 5 of 10 (Resident #1, #2, #3, #4, #5) reviewed for misappropriation and exploitation. 1.The facility failed to ensure Resident #1 was free from exploitation when the former BOA accepted cash payment for Resident #1's June, July, August, and [DATE] payments (totaling $3,440.00), with only $2,184.00 deposited within a facility account on [DATE] (after BOA termination date) leaving $1,256.00 unaccounted for. 2. The facility failed to ensure Residents #2, #3, and #4 were free from exploitation when the former BOA created and cashed checks for Residents #2, #3, and #4 for personal need items without authorization from the resident or resident representative and no personal need items were provided to the residents involved. 3. The facility failed to ensure Resident #5 was free from exploitation when the former BOA made a money order (provided 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 observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 2 of 17 residents reviewed for care plans. (Residents #4 & #54) 1. The facility did not have a care plan to address Resident #4's hospice care. 2. The facility did not have a care plan to address Resident #54's indwelling urinary catheter (a thin, flexible tube inserted into the bladder to drain urine) or catheter care. These failures could place residents at risk of not having their individual needs met and not receiving needed services. Findings included: 1. Record review of the face sheet dated 08/20/25 indicated Resident #4 was a [AGE] year-old male admitted on [DATE]. His diagnoses included cerebral palsy (a congenital disorder of movement, muscle tone, or postured due to abnormal brain development often before birth) and muscle wasting and atrophy (waste away, especially because of degeneration…

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 record review, the facility failed to ensure a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 6 residents (Resident #25) reviewed for respiratory therapy. The facility failed to keep the oxygen concentrator filter clean for Resident #25. This failure could place residents at risk of receiving incorrect or inadequate oxygen support which could result in a decline in health. Findings included: Record review of Resident #25's face sheet dated 08/18/25, indicated he was a [AGE] year-old male readmitted on [DATE] with diagnoses of chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), respiratory failure (a condition where the lungs are unable to adequately exchange oxygen and carbon dioxide resulting in dangerously low oxygen levels in the blood) and heart…

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 and record review, the facility failed to ensure its residents were free of any significant medication errors for 4 (Resident #1 Resident #2, Resident #3 and Resident #4) of 10 residents reviewed for medications. The facility failed to administer Midodrine (medication to increase blood pressure) per parameters stated in physicians' orders for a total of 10 doses in [DATE] for Resident #1.The facility failed to administer Midodrine per parameters stated in physicians' orders for a total of 11 doses in [DATE] for Resident #1.The facility failed to administer Midodrine per parameters stated in physicians' orders for a total of 1 dose in [DATE] for Resident #2.The facility failed to hold Midodrine per parameters stated in physicians' orders for a total of 5 doses in [DATE] for Resident #3.The facility failed to hold Midodrine per parameters stated in physicians' orders for a total of 3 doses in [DATE] for Resident #3.The facility failed to hold Nifedipine (medication to lower blood pressure) per…

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 and record review the facility failed to ensure the rights of residents to be free from abuse for 1 of 10 residents (Resident #2) reviewed for abuse. The facility failed to ensure Resident #2 was free from verbal abuse by HSK A. On 03/29/25 HSK A had a verbally aggressive argument with Resident #2 over cigarettes. Resident #2 told HSK A she wished she would shut up and HSK A got up from her chair and told Resident #2 to make her shut up. This failure could place residents at risk for abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life. Findings included: Record review of Resident #2's face sheet dated 05/09/25 indicated Resident #2 was a [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of the brain), major…

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 interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported, immediately but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or bodily injury, to the administrator of the facility and to other officials, including the State Survey Agency in accordance with State law through established procedures for 1 of 10 residents (Resident #2) reviewed for reporting allegations of abuse. The facility failed to ensure allegations of abuse were reported to the Abuse Coordinator Immediately. HSK B wrote a concern form and left it in the mailbox outside of the HR door on 03/29/25 about the witnessed verbal exchange between Resident #2 and HSK A. The facility failed to report allegations of abuse to HHSC within two hours of being notified of the abuse allegation. The Administrator did…

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 interview and record review the facility failed to have evidence alleged violations were thoroughly investigated to prevent further abuse for 1 of 10 residents (Resident #2) reviewed for abuse. The facility failed to thoroughly investigate after HSK A had a verbally aggressive argument with Resident #2 over cigarettes. Resident #2 told HSK A she wished she would shut up and HSK A got up from her chair and told Resident #2 to make her shut up. This failure could place residents at risk of not having allegations of abuse, neglect or exploitation investigated properly to prevent re-occurrence. Findings included: Record review of Resident #2's face sheet dated 05/09/25 indicated Resident #2 was a [AGE] year old female admitted to the facility on [DATE]. Her diagnoses included dementia (a condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking, and often with personality change, resulting from organic disease of 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 interview and record review, the facility failed to ensure pharmacy procedures to ensure an accurate accounting of all controlled drugs and the licensed pharmacist failed to ensure the drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled for 2 of 4 medication carts reviewed for narcotic counts. (300 Hall Nurse Cart and 200/500 Halls Medication Aide Cart) The facility did not ensure staff were conducting accounting of Controlled Drugs at shift change on the 300 Hall Nurse Cart and 200/500 Halls Medication Aide Cart. The Pharmacy Consultant did not ensure the Controlled Drugs - Count Record forms had signatures of the staff indicating the Controlled Drugs were reconciled. These failures could place residents at risk for misappropriation and drug diversion. Findings included: Record review of the June 2024 Controlled Drugs - Count Record form on the 300 Hall Nurse Cart indicated: *on the day shift the nurse going off shift did not sign the form on 1st, 5th, 6th, 10th, 12th, 13th, 19th, 20th, and 21st; *on the night…

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 record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access, for 2 of 2 medications reviewed for security. The facility did not ensure clonidine (medication to treat elevated blood pressure) and a Fentanyl patch (narcotic opioid pain medication) medication was stored securely when it was left unattended at the nursing station. This failure could place residents at risk for harm by misappropriation of property and drug diversion. Findings included: During an observation on 06/23/24 at 12:28 p.m. of the nurse station, a card of clonidine (medication to treat elevated blood pressure) and a Fentanyl (narcotic opioid pain medication) patch were left on the desk unattended by a nurse or medication aide and accessible to staff, residents, and visitors. During an interview on 06/23/24 at 12:30 p.m., the Administrator was shown the card of clonidine and Fentanyl patch were on the desk of the nurse station unattended by a nurse 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 Based on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan for each resident, that included measurable objectives and timeframes to meet a resident's needs identified in the comprehensive assessment for 1 of 20 residents reviewed for following physician orders. (Resident #27) The facility did not apply Resident #27's hand splint as ordered by the physician This failure could place the residents at risk of a decline in their range of motion. Findings included: Record review of physician orders dated June 2024 indicated Resident #27, admitted [DATE], was an [AGE] year-old female with diagnoses of muscle wasting and atrophy and cerebral infarction (a condition that occurs when blood flow to the brain is disrupted causing the brain tissue to die). The orders indicated the resident was to have a resting hand splint to the right upper extremity to prevent contracture. The hand splint was to be removed every night. Record review of the quarterly MDS…

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 record review, the facility failed to ensure that residents receiving enteral feeding received appropriate care and services to prevent complication of enteral feeding for 1 of 1 resident (Resident #272) reviewed for enteral feeding. The facility failed to ensure LVN A verified placement of Resident #272's G-tube by checking for tube placement before enteral administration of water and medications. The facility failed to ensure LVN A administered the flushes and medications using gravity. These failures could place residents receiving enteral nutrition and medications at increased risk of not receiving proper nutrition, infection, aspiration, and possible injury. Findings included: Record review of Resident #272's physician orders dated June 2024 indicated he was a [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included dysphagia (difficulty or discomfort swallowing). Orders indicated he was NPO (nothing by mouth), was to receive all feedings and…

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 record review, the facility failed to ensure parenteral care and services were administered consistent with professional standards of practice for 2 of 3 residents reviewed for intravenous fluids. (Resident #39 and 82) *The facility failed to change Resident #39 and 82's midline catheter dressing in accordance with the resident's plan of care. (Midline catheter is an ultrasound guided catheter inserted in the upper arm peripheral veins for IV access) This failure could place residents at risk of not receiving the appropriate IV care and services. Findings included: 1. Record review of physician orders dated April 2023 indicated Resident #39, admitted [DATE], was [AGE] years old with diagnoses of emphysema and COPD (chronic obstructive pulmonary disease). Record review of a physician order dated 04/13/23 for Resident #39 indicated Midline catheter to right arm - change sterile transparent dressing to insertion site using sterile technique Q (every) weekly and PRN (as needed) if…

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 record review, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and drug records were in order and that an account of all controlled drugs was maintained for 1 of 18 residents (Resident #46) reviewed for pharmacy services. LVN A did not destroy the used fentanyl (scheduled II controlled medication used for severe pain) patch in a sharps container per policy and with a witness for destruction after the patch was removed from Resident #46. The facility did not ensure records for Resident #46 were complete with witness signatures for 5 days on control sheet for disposition of discarded fentanyl patch. This failure could place the residents at risk of drug diversion. Findings included: Record Review of physician orders summary dated April 2023 indicated Resident #46 admitted [DATE] and was [AGE] years old with diagnoses of chronic pain and kidney cancer. The orders…

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.