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, patternF686Feb 9, 2023

  Based on record review, observation and interviews with Orthopedic Physician Assistant (PA), Wound Nurse, Wound Physician, Medical Director (MD) #2, Director of Nursing (DON) #2, Administrator #2, Nurse Practitioner (NP) #2 and family, the facility failed to prevent the development of a pressure ulcer, protect Resident #16's skin under an immobilizer used following a fractured distal femur (the area of the leg just above the knee joint), perform skin checks under the immobilizer and assess skin. At the first orthopedic follow up appointment, an abrasion was identified. Orders were given to pad an abrasion and consult with a wound physician. The orders were not implemented. Skin checks continued not to be done following the identification of the pressure ulcer. […]

• Immediate jeopardy, patternF835Feb 9, 2023

  Based on record review and Administrator #1 and Director of Nursing (DON) #1 interviews the facility administration failed to have effective systems in place to prevent, identify, assess, treat, and manage residents with and at risk for pressure sores. This failure resulted in Resident #16 developing an avoidable abrasion under her left leg immobilizer identified on 09/06/22 at an orthopedic consult visit. The abrasion went untreated and area deteriorated into an unstageable pressure ulcer (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) on 9/13/22. […]

• Immediate jeopardy, isolatedF580Feb 9, 2023

  Based on record review and staff, Wound Nurse, Director of Nursing (DON) #2, Medical Director (MD) #2, and Nurse Practitioner (NP) #2 interviews, the facility failed to notify the MD #2 or NP #2 that Resident #16's developed an abrasion to her left lateral calf under her immobilizer on 9/6/22 resulting in no assessment or treatment until 9/13/22 when the area was discovered as an unstageable pressure ulcer (Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar). […]

• Actual harm, isolatedF600Feb 9, 2023

  Based on staff family, emergency room (ER) Physician, Medical Director #2, Nurse Practitioner (NP) #1 interviews and record review, the facility failed to protect the resident from injury of unknown origin (right proximal tibia/fibula fracture) resulting in physical harm. This was for 1 (Resident #16) of 8 residents reviewed for accidents. The findings included: Resident #16 was admitted on [DATE] with cumulative diagnoses of Dementia, Congestive Heart failure, Chronic Kidney Disease, Coronary Artery Disease, and osteoporosis. Review of Resident #16's care plan included a care plan for osteoporosis with a risk for fractures dated last revised on 7/9/21. […]

• Actual harm, isolatedF626Feb 9, 2023

  Based on record review and Hospital Case Manager, Ombudsman, Business Office Manager, Regional Director, Former Administrator, and current Administrator interviews, the facility failed to permit a resident to return to the facility following a facility-initiated transfer to the hospital for 1 of 1 resident reviewed for hospital transfer. Resident #106 was medically stable to return on [DATE] when the facility refused to readmit the resident. The resident remained in the hospital until [DATE] where she expired. Based on the reasonable person concept a resident transferred to the hospital for an acute condition expects to return to their home at the facility following stabilization at the hospital. […]