Liberty Ridge Health & Rehab

Based on observation, resident and staff interviews, and facility documentation review, the facility staff failed to follow the posted menu, affecting residents on 2 of 2 nursing units. The findings included: The facility staff failed to follow the posted menu with regards to the vegetable. On 6/3/24 at 3 p.m., the resident council met with a surveyor. During the meeting, residents verbalized that they do not get what is posted on the menu. On 6/3/24 at approximately 4 p.m., observations were made of the menu posting on each of the resident units. The evening meal was listed as chicken tenders, greens, and macaroni and cheese. On 6/3/24, in the afternoon, the menu was reviewed, and it listed the evening meal as being chicken tenders, seasoned greens, macaroni and cheese, and fresh fruit cup. On 6/3/24 at 04:24 p.m., observations were conducted in the kitchen of the evening meal that was being prepared by the cook/other staff #6 (OS #6). The cook said that she was preparing broccoli because they didn't have greens. When asked what the process is when they do not have what is on 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 observations, resident and staff interviews, and facility documentation review, the facility failed to provide foods that were at appetizing temperatures on two of two nursing units, affecting multiple residents. Findings include: The facility staff failed to serve foods at an appetizing temperature on the long-term care unit. On 6/3/24 at 3 p.m., a meeting was held with the resident council, of which seven residents were in attendance. During the meeting, the residents verbalized that the food is not hot. On 6/3/24 at 3:15 p.m., an interview was conducted with Resident #51 (R51) who stated, The food is lukewarm, coffee is not hot. I could probably get someone to heat it up or get me another cup, but then you have to wait. On 6/3/24 at 4:24 p.m., observations were conducted in the kitchen. The dietary manager was asked how coffee was prepared and distributed to residents. The dietary manager explained that coffee is brewed in the kitchen, cooled with ice, and then put into coffee dispensers that are sent to the dining room. The dietary manager stated that from the dining…

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, staff interview, and facility documentation review, the facility staff failed to store and prepare food in accordance with food safety standards in the main kitchen having the potential to affect residents on 2 of 2 resident care units. The findings included: 1. The facility staff failed to store foods in a manner to prevent contamination and failed to label and date items in the freezer and refrigerators. On 6/3/24 at 10:35 a.m., an initial tour of the kitchen was conducted with the dietary manger. This observation revealed that in the dry storage room there was two bags of pasta that were open to air. One bag of pasta had the bag tied but a hole had also been ripped into the bag. Neither bag was dated as to when they were opened. There was also a bag of brown sugar that was open to air and didn't have any date as to when it was opened, or when it was to be used by. When asked how such items were expected to be stored, the dietary manager stated, In a re-usable bag. There were three containers that held dry cereal that had been removed from the original…

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 resident interview, staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure two residents (Resident #70- R70) and (Resident #67- R67), were free from unnecessary psychotropic medications, in a survey sample of 21 residents. The findings included: 1. For Resident #70 (R70), the facility staff failed to limit an order to 14 days for the psychotropic medication Ativan, an antianxiety medication, ordered to be given as needed. On 6/3/24 at 11:51 a.m., R70 was observed in their room and appeared comfortable. On 6/3/24 and 6/4/24, a clinical record review was conducted of R70's chart. This review revealed that R70 had an active physician order for Ativan 0.5 mg tablet to be administered every 4 hours as needed (prn) for anxiety or agitation. The order was written 4/15/24, had no stop date, and at the time of survey, it remained an active order. On 6/4/24 at 2:50 p.m., an interview was conducted with CNA #1 (certified nursing assistant). When asked about…

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, staff interview, facility document review and clinical record review, the facility staff failed to accurately label a medication and discard an expired medication on one of two units (skilled unit). The findings include: 1. The medication metoprolol administered to Resident #132 during a medication pass observation was labeled with an incorrect dosage. A medication pass observation was conducted on 6/4/24 at 7:39 a.m., with licensed practical nurse (LPN #2) administering medications to Resident #132 (R132). Among the medications administered was a half tablet of metoprolol 25 mg (milligrams) for a 12.5 mg dose. R132's pharmacy supply card of metoprolol was labeled with instructions to give 25 mg twice per day. There was nothing documented on the supply card label indicating the half tablet (12.5 mg) dose or of any recent dose change. R132's clinical record documented a physician's order dated 5/30/24 for metoprolol 25 mg with instructions to give 1/2 (one half) tablet twice per day for treatment of hypertension. On 6/4/24 at 8:26 a.m., LPN #2 was interviewed…

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 staff interview and clinical record review, the facility staff failed to ensure an accurate clinical record for one of twenty-one residents in the survey sample (Resident #68) The findings include: Resident #68 (R68) was admitted to the facility with diagnoses that included anemia, atrial fibrillation, diabetes and arthritis. The minimum data set (MDS) dated [DATE] assessed R68 as cognitively intact. R68's clinical record documented a Durable Do Not Resuscitate Order signed by the physician and resident on 5/19/24. R68's clinical record also documented an Advance Care Planning Tracking Form dated 5/21/24 for Resident #73. Resident #73's Advance Care Planning Tracking Form documented a verified full code status and was dated 5/21/24. On 6/4/24 at 10:54 a.m., the medical records clerk (other staff #1) was interviewed about R73's advance directive checklist found in R68's clinical record. The medical records clerk stated that the social services department was responsible for entering forms regarding…

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, staff interview, and facility document review the facility staff failed to ensure food was stored and prepared in a sanitary manner in the main kitchen of the facility. Findings include: On 2/8/22 beginning at 10:55 a.m. the kitchen was inspected with the dietary manager (DM). The refrigerator contained 4 plastic bins with approximately 50 half-pint containers of milk that were expired as of 2/7/22. Another plastic bin contained approximately 20 cartons of expired milk for a total of approximately 220 cartons of expired milk. The DM was asked about the amount of milk, and he replied, The delivery man used to come twice per week, he has only been coming once a week for the past month. I had this same issue last week, and I'm trying to get him back twice a week. There was no explanation as to why he has reduced the delivery schedule . On 2/8/22 at 12:00 p.m. an employee, identified as the cook, was observed without a hair restraint covering over her hair. When asked why she did not have on a hair restraint, she stated I've been running around here trying to get…

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 clinical record review and staff interview, the facility staff failed to accurately complete a PASARR (Preadmission Screening and Resident Review) for one of 22 residents in the survey sample, Resident #62. Resident #62's PASARR did not accurately document the diagnosis of schizophrenia. The findings include: Resident #62 was admitted to the facility on [DATE] with diagnoses that included foot fracture, hypertension, hypotension, muscle weakness, hyperlipidemia, depression, and schizophrenia. The most recent minimum data set (MDS) dated [DATE] was a 5 day admission assessment and assessed Resident #62 as cognitively intact for daily decision making with a score of 14 out of 15. Under Section I - Active Diagnoses: Psychiatric/Mood Disorders, Resident #62 was assessed with depression and schizophrenia. Resident #62's electronic clinical record was reviewed on 02/08/22. Observed on the physician's orders was the following: Trihexyphenidyl HCI Table 5 MG Give 0.5 tablet by mouth two times a day for…

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 staff interview and clinical record review, the facility staff failed to ensure a complete and accurate clinical record for one of 22 residents in the survey sample: Resident # 31. Resident 31 had a PASARR (Preadmission Screening and Resident Review) form in the clinical record that was incomplete and inaccurate. Findings include: Resident # 31 was admitted to the facility 6/2/13 with diagnoses to include, but were not limited to: muscle weakness, pain in right hip, heart failure, high blood pressure, and vitamin D deficiency. The most recent MDS (minimum data set) was a quarterly review dated 1/7/22 and had Resident # 31 as being cognitively intact with a summary score of 13 out of 15. The electronic medical record (EMR) was reviewed 2/9/22 at approximately 3:00 p.m. A PASARR Level I, DMAS form 95 was observed scanned into the miscellaneous documents of the clinical record. The PASARR did not identify Resident #31 has having a current mental illness. Per review of the clinical record, Resident # 31 did not have a diagnosis of a mental illness, or dementia. The PASARR form,…

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, staff interview and facility document review, the facility staff failed to ensure infection control practices were followed for one of three isolation rooms on the COVID unit. Findings include: On 02/09/22 10:36 AM, the COVID unit/rooms were observed. Each room had a plastic barrier at each door and two isolation carts were in the hall. Both isolation carts had gowns, gloves and N-95 masks, but there was no eye protection in either of the isolation carts. Each of the rooms had signage attached to the door frame, which documented: .droplet-contact precautions .perform hand hygiene, wear a mask before entering, gown before entering, gloves before entering, eye protection before entering .red room. CNA (certified nursing assistant) #3, was informed there was no eye protection/goggles on the carts and was asked where the eye protection was located. CNA #3 stated that she didn't know, but would try to find the goggles they use. CNA #3 looked in the supply room and did not find any. CNA #3 stated that she thought housekeeping restocked the isolation cart, but wasn't…

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 staff interview and facility document review, the facility staff failed to meet the requirement for staff COVID-19 vaccination. The facility staff's COVID-19 vaccination rate was 93.5% instead of the required 100% compliance rate as required. The findings include: On 02/08/2022 at 10:21 a.m. during the entrance conference, the administrator and director of nursing (DON) were interviewed regarding the facility's staff COVID-19 vaccination rate. The DON stated, We're not at 100%, but we're working on it and are providing onsite COVID-19 vaccines for all staff. The facility's staff was requested to provide the current COVID-19 vaccination status for all staff members including any contract staff. A review of the NHSN (National Health Safety Network) data dated 1/23/2022 documented the facility's reported staff vaccination rate was 83.2%. A review of the facility's COVID-19 staff vaccination matrix documented the facility employed 123 staff, that included 109 staff completely vaccinated, 5 staff partially vaccinated, and 1 staff with a pending medical exemption which equaled…

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, resident interview, staff interview and clinical record review, the facility staff failed to implement interventions for the prevention and/or treatment of pressure ulcers for three of 21 residents in the survey sample. Wound treatment orders for Resident #24's toe ulcer were not implemented as recommended by the wound consultant and per manufacturer's recommendation for administration of Santyl ointment. Resident #43's heel ulcer was observed without a physician ordered dressing and protective boot in place. Resident #15 was observed without a protective boot in use for pressure ulcer prevention. The findings include: 1. Resident #24 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #2 included diabetes, neuropathy, asthma, gout, anxiety, depression, hypertension, atherosclerotic heart disease, chronic pain, dementia, heart failure and fractured clavicle. The minimum data set (MDS) dated [DATE] assessed Resident #24 as cognitively intact. During…

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, resident interview, staff interview and clinical record review, the facility staff failed to implement interventions to minimize pain during a dressing change for one of 21 residents in the survey sample. Resident #24 was not offered any interventions to minimize pain/discomfort during a dressing change to a left toe wound. The findings include: Resident #24 was admitted to the facility on [DATE] with a re-admission on [DATE]. Diagnoses for Resident #2 included diabetes, neuropathy, asthma, gout, anxiety, depression, hypertension, atherosclerotic heart disease, chronic pain, dementia, heart failure and fractured clavicle. The minimum data set (MDS) dated [DATE] assessed Resident #24 as cognitively intact. During an interview with Resident #24, the resident stated new shoes rubbed a blister on one of her left toes and nurses provided daily dressing changes to the open wound. On 2/17/21 at 7:55 a.m., with the resident's permission, registered nurse (RN) #1 was observed changing the dressing…

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.