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.

• Actual harm, isolatedF689Oct 14, 2021

  Based on record review and staff and physician ' s interviews the facility failed to transfer a resident in a manner that prevented an injury that resulted in a toe fracture during a transfer by an outside transport company for 1 of 3 residents reviewed for accidents (Resident #3). The findings included: Resident #3 was admitted to the facility on [DATE] and had a diagnosis of [CONDITION(S)], diabetes and diabetic [CONDITION(S)]. The most recent Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was cognitively intact, was not ambulatory and required total assistance with transfers. […]

• No harm, potential for more than minimal, widespreadF908Oct 9, 2024

  Based on lunch meal tray line observation, and staff interviews, the facility failed to maintain the plate warmer, essential equipment to the dietary department, in good operating condition, as evidenced by the plate warmer being inoperable. The findings included: An observation of the lunch meal tray line occurred on 10/09/24 at 11:50 AM. The two cylinder plate warmer was not plugged in or warm to the touch. In an interview on 10/09/24 at 12:04 PM Dietary Staff #1 stated the plate warmer had not worked for over 2 months. In an interview on 10/09/24 at 12:20 PM the Maintenance Assistant revealed he had worked at the facility for 2 months and was not aware the plate warmer was not working or had attempted to repair it. […]

• No harm, potential for more than minimal, patternF761Jun 15, 2023

  Based on observation and staff interviews, the facility failed to maintain a medication storage refrigerator within the recommended temperature range for 1 of 1 medication refrigerator reviewed (100 Hall medication storage refrigerator). Findings included: An observation of the medication storage refrigerator located in the 100 hall medication storage room was made on 6/14/23 at 11:59 AM with Nurse #1. The refrigerator thermometer was observed at 30 degrees Fahrenheit ( F). Nurse #1 viewed the refrigerator thermometer and stated it appeared to read between 30 and 32 degrees. The June 2023 temperature monitoring log for the medication storage refrigerator had been noted daily with temperatures between 38 F and 40 F. […]

• No harm, potential for more than minimal, patternF812Mar 3, 2022

  Based on observations and staff interviews the facility failed to date potential hazardous food items stored for use in 1 of 1 walk-in cooler and 1 of 1 reach-in cooler. This practice had the potential to affect food served to residents. The findings included: 1. a. Initial observation of the kitchen walk-in cooler on 02/28/2022 at 11:24 AM revealed the following foods were unlabeled and undated: 1 opened container of thickened liquid 1 opened package of cheese b. Initial observation of the kitchen reach-in refrigerator on 02/28/2022 at 11:26 AM revealed the following food was unlabeled and undated: 1 bag of opened shredded cheese c. […]

• No harm, potential for more than minimal, isolatedF803Nov 25, 2025

  Based on observations, record reviews, and interviews with staff, the facility failed to follow the approved menu for 2 of 4 residents on a pureed diet (Residents #18 and #38). The findings included: The Week 1 dietitian approved menu indicated residents on a pureed diet were to receive a #6 scoop (equal to 5.3 ounces) of pureed vegetable chili and a #10 scoop (equal to 3.25-4 ounces) of pureed cornbread. The Diet Report dated 11/24/25 documented 4 residents had orders for a pureed diet. a. Resident #18 was admitted to the facility on [DATE] with diagnoses including dysphagia (trouble swallowing), hospice care, and weight loss. Resident # 18's current physician orders reviewed 11/24/25 documented she was to receive a pureed no added salt diet. b. […]