Liberty Center for Rehabilitation and Nursing

In the surveyor’s words

From the most serious findings on record at Liberty Center for Rehabilitation and Nursing, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jan 18, 2024

  Based on review of clinical records, facility documentation, and interviews with staff, it was determined the facility failed to provide adequate supervision consistent with the resident's needs, and professional standards of practice for an ambulatory resident diagnosed with dementia, with a history of wandering, and at risk for elopement. When not properly supervised, the resident eloped from the facility, and was found wandering the streets, for one of nine residents reviewed at risk for elopement (Resident R1). The deficiency was identified as Immediate Jeopardy past non-compliance. […]

• Actual harm, isolatedF686Dec 15, 2022

  Based on clinical record review, observations of resident care and services, and interviews with staff, it was determined that the facility failed to ensure that one of three residents reviewed for pressure ulcers was monitored, assessed and received the necessary services to prevent new ulcers from developing, resulting in actual harm of pressure ulcer development for Resident R28. Findings include: Review of Resident R28's clinical record revealed an admitted [DATE] diagnosed with cerebral palsy, severe intellectual disabilities, epilepsy, encephalopathy (A broad term for any brain disease that alters brain function or structure), acute respiratory failure with hypoxia, retention of urine with use of a Foley catheter, a tracheostomy used to assist in breathing, and a gastrostomy (feeding… […]

• No harm, potential for more than minimal, widespreadF812Jun 5, 2025

  Based on review of facility documentation, observations, and staff interview it was determined that the facility failed to ensure food was stored and prepared in accordance with standards for food service safety. Findings Include: Review of facility policy Food Storage revealed temperatures for the freezer should be 0 degrees or below and must be recorded daily. A tour of the main kitchen was conducted on June 2, 2025, at 10:00 a.m. with the Food Service Director, Employee E27, which revealed the following: Observations in the outbuilding containing the walk-in freezer revealed a steel entry door that was not closed properly, and the bottom of the door was rusted through and did not seal. […]

• No harm, potential for more than minimal, widespreadF585Oct 13, 2023

  Based on review of policies, as well as interviews with residents and staff, it was determined that the facility failed to ensure that residents and/or their representatives could file a grievance/concern anonymously by failing to ensure that information on how to file a grievance or complaint was available to residents or their representatives without asking. Findings include: A review of the facility policy Grievance-Complaints, filing, revised April 1, 2017 stated Residents and their representatives have the right to file grievances, either orally or in writing, to the facility staff or to the agency designated to hear grievances (e.g., the State Ombudsman). On October 11, 2023, at 10:59 a.m. […]

• No harm, potential for more than minimal, widespreadF812Jan 27, 2022

  Based on observations, interviews with staff, and a review of facility policies and documentation, it was determined that the facility did not ensure that food was stored, prepared, and served in accordance with professional standards for food service safety. Findings include: Review of the undated facility policy titled, Food Receiving and Storage, revealed, All foods stored in the refrigerator or freezer will be covered, labeled and dated. Wrappers of frozen foods must stay intact until thawing. A tour of the Food Service Department conducted at approximately 9:35 a.m. […]