Liberty Commons Nursing and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, patternF580Jul 26, 2024

  Based on record review and interviews with staff, Medical Director (MD) and Physician Assistant (PA), the facility failed to notify the physician when a resident had signs of Clostridium Difficile (C. difficile) that included persistent loose, watery, mushy, and odorous stool. From 2/9/24 through 2/27/24 the resident experienced these abnormal stools. The physician was notified on 2/13/24 of the abnormal stools, but was not made aware of the ongoing issue until 2/27/24 when it was brought to the nurse's attention by the resident's family member. Upon discharge from the facility on 2/28/2024, the resident was immediately transported by a family member directly to her Primary Care Physician's office where she was tested for C. Difficile, and the lab test was positive for C. […]

• Immediate jeopardy, patternF684Jul 26, 2024

  Based on record review and family, staff, Medical Director, and Physician Assistant interviews, the facility failed to comprehensively assess a resident who was presenting with signs of Clostridium Difficile (C. difficile) (According to the Centers for Disease Control and Prevention (CDC): C. difficile-is a highly contagious bacteria that causes diarrhea and inflammation of the colon and can be life-threatening; symptoms include 3 or more foul smelling watery stools a day lasting longer than 1 day, and abdominal cramping), to determine the cause of the watery stools, identify the seriousness of the symptoms, and implement effective interventions to treat repeat watery stools which started on 2/09/2024. […]

• Immediate jeopardy, patternF760Apr 5, 2022

  Based on record review, staff interviews, the facility Pharmacist, the Pharmacy Manager, and Physician interviews, the facility 1.a) failed to transcribe a medication order upon admission resulting in failure to administer 12 doses of a medication ([MEDICATION(S)]) an anticonvulsant used in the treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . b) failed to clarify a medication order upon admission resulting in failure to administer 4 doses of the anticonvulsant medication [MEDICATION(S)] (prescribed to treat and prevent seizures) which resulted in the resident having a [CONDITION(S)] and being transported to the hospital for 1 of 1 resident reviewed (Resident # 87). […]

• Immediate jeopardy, isolatedF756Apr 5, 2022

  Based on record review, staff interviews, the Consultant Pharmacist, and Physician interviews the facility failed to act upon the recommendations contained in the Consultant Pharmacist's initial Medication Regimen Review (MRR) to follow up on an order entry for [MEDICATION(S)] an anticonvulsant used in the treatment of [CONDITION(S)] (a brain disorder that causes seizures) resulting in failure to administer 12 doses of the medication for 1 of 1 resident whose medications were reviewed (Resident #87). Immediate Jeopardy began on 02/03/22 when the facility failed to act upon the Consultant Pharmacist's initial MRR to follow up on the order entry for the [MEDICATION(S)] resulting in 12 missed doses. […]

• Actual harm, isolatedF686Feb 29, 2024

  Based on record review, staff and the Senior Director of Compliance for the Orthopedic Office/Registered Nurse (RN) and Physician interviews, the facility failed to contact the Orthopedic office for clarification and instructions for removal of the orthopedic pneumatic (air pressure) boot, dressing changes and skin assessments on a resident's left ankle (Resident #7) after her follow-up appointment with the physician's assistant on 12/21/2023. Resident #7 developed deep tissue injuries (DTI) to the bottom of her left great toe, left lateral foot and left heel. This was for 1 of 3 residents reviewed for pressure ulcers. […]