Liberty Commons

In the surveyor’s words

From the most serious findings on record at Liberty Commons, in the surveyor’s own words.

• Actual harm, isolatedF689Apr 12, 2022

  Based on records reviewed and interviews, for one of three sampled residents, (Resident #1), the Facility failed to ensure his/her safety was maintained to prevent an incident/accident with injury, when nursing staff applied a hot pack to his/her right lower abdomen, and as a result Resident #1 sustained a large second degree burn (partial thickness burn, appears red, blistered, may be swollen and painful) to that area which required treatment with [MEDICATION(S)] (used to treat infections of second and third - degree [CONDITION(S)]) two times a day for 12 days, treatment was changed to Santyl ointment ([MEDICATION(S)] medication used to remove dead tissue from severely burned skin so that the skin can start to heal) and treatment was still on-going at the time of the survey. […]

• No harm, potential for more than minimal, widespreadF585Jan 9, 2026

  Based on observation, interviews, and document review, the facility failed to ensure that residents were fully aware of the grievance process. Specifically, for 11 of 11 residents attending the resident group meeting during the survey, the facility failed to ensure their grievance policy included the right to file grievances anonymously and failed to ensure residents were aware of and had access to grievance forms, and were aware they could formulate grievances anonymously, should they choose not to alert a staff member of their concern(s).Findings include:Review of the facility's policy titled Grievances & Resolution of Other Issues, undated, failed to indicate residents and/or their representatives had the right to file grievances anonymously.On 1/7/26 at 9:58 A.M., the surveyor toured… […]

• No harm, potential for more than minimal, patternF565Jan 9, 2026

  Based on review of Resident Council Minutes, a resident group meeting, interviews, and record reviews, the facility failed to ensure grievances brought forward from the Resident Council were addressed and promptly resolved to ensure the residents felt their concerns were acted upon timely and included the facility response to the group.Findings include:Review of the facility's policy titled Resident Council, undated, indicated but was not limited to the following:-The purpose of the Resident Council is to provide a forum for: a. Residents to have input in the operation of the facility; b. Discussion of concerns; c. Consensus building and communication between residents and facility staff; and d. […]

• No harm, potential for more than minimal, patternF605Jan 9, 2026

  Based on record review and interview, the facility failed to ensure that each resident's drug regimen was free from unnecessary psychotropic medications to promote or maintain the residents' highest practicable mental, physical, and psychosocial well-being. Specifically, the facility failed to ensure for one Resident (#84), out of a total sample of 26 residents, that as needed (PRN) use of Ativan (treats anxiety) was limited to 14 days and the prescriber documented an evaluation of the Resident's current condition and the appropriateness for continued use prior to extending its duration.Findings include:Review of the facility's policy titled Psychotropic Medication Use, dated 2001, indicated the following:-Psychotropic medications are not prescribed or given on a PRN basis unless that… […]

• No harm, potential for more than minimal, patternF658Jan 9, 2026

  Based on observation, interview, and record review, the facility failed to provide care and services consistent with professional standards for three Residents (#109, #84, #138), out of a total sample of 26 residents. Specifically, the facility failed:1. For Resident #109, to complete weekly skin assessments as ordered by the physician;2. For Resident #84, to implement a physician's order for head-of-bed elevation positioning; and 3. For Resident #138, to obtain a physician's order for an Registered Nurse (RN) pronouncement of death.Findings include:Review of [NAME], Manual of Nursing Practice 11th edition, dated 2019, indicated the following:-The professional nurse's scope of practice is defined and outlined by the State Board of Nursing that governs practice. […]