Liberty Care & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Liberty Care & Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Dec 15, 2023

  Based on observation, interview, record review, and review of the facility's policy, it was determined the facility failed to ensure residents were protected from abuse, including resident to resident abuse for four (4) of seven (7) sampled residents (Resident #1, Resident #2, Resident #6, and Resident #7). 1. On 09/05/2023, Resident #2 was observed by staff in Resident #1's bed (a resident of the opposite sex) with his/her hand in Resident #1's genital area. In addition, facility staff confined Resident #1 and Resident #2 to their rooms after the incident in order to allow one (1) staff member to monitor both residents at the same time. 2. On 04/16/2023, Resident #2 was observed by staff sitting on Resident #6's bed with his/her hands under a blanket covering Resident #6's lap. 3. […]

• Immediate jeopardy, isolatedF609Dec 15, 2023

  Based on interview, record review and review of the facility's policy, it was determined the facility failed to ensure allegations of abuse were reported to the State Agencies and local law authorities immediately, but no later than two (2) hours, after the allegation was made for four (4) of seven (7) sampled residents (Resident #1, Resident #2, Resident #6, and Resident #7). 1. On 09/05/2023, Resident #2 was observed in Resident #1's bed (a resident of the opposite sex) with his/her hand in Resident #1's genital area. However, the facility failed to notify the appropriate State Agencies and local law authorities. 2. On 04/16/2023, Resident #2 was observed sitting on Resident #6's bed with his/her hands under a blanket covering Resident #6's lap. […]

• Immediate jeopardy, isolatedF656Dec 15, 2023

  Based on interview, record review, review of the facility's policies, review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, and review of the Minimum Data Set (MDS) Coordinator Job Description, it was determined the facility failed to ensure a comprehensive person-centered care plan was developed and implemented to meet a resident's medical, nursing, and mental and psychosocial needs for four (4) of seven (7) sampled residents (Resident #1, Resident #2, Resident #6, and Resident #7). 1. On 09/05/2023, Resident #2 was observed in Resident #1's bed (a resident of the opposite sex) with his/her hand in Resident #2's genital area. […]

• Immediate jeopardy, isolatedF835Dec 15, 2023

  Based on interview, record review, review of the Director of Nursing and Administrator's Job Description, and review of the facility's policies, it was determined the facility failed to ensure it was administered in a manner to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychological well-being of each resident and to ensure prevention of abuse. Staff interviews and record review revealed the facility failed to provide adequate supervision to residents to prevent abuse, failed to ensure the Comprehensive Care Plans (CCPs) were developed and implemented to prevent abuse, and failed to notify the appropriate State Agencies and local law authorities of allegations of abuse. […]

• Actual harm, isolatedF657Jun 14, 2024

  Based on interview, record review, and review of the facility's policies, the facility failed to review and revise the comprehensive care plan (CCP) for three (3) of 42 sampled residents, (Residents (R), R29, R37, and R49). Although staff was aware R37 had a history of grabbing onto the wheelchair wheels of her Evolution Mobility wheelchair when she did not want to be transported by staff, the facility did not revise her Comprehensive Care Plan (CCP) with safety interventions to prevent injury related to this behavior. On 06/09/2024, R37 was being transported by staff to her room when her hand was caught in the wheel spokes of her wheelchair, causing her to sustain a fracture and lacerations to her left index finger. […]