Liberty Commons Nursing & Rehab Center of Southpor

In the surveyor’s words

From the most serious findings on record at Liberty Commons Nursing & Rehab Center of Southpor, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF847Aug 13, 2026

  Based on record review and staff interviews, the facility failed to ensure the arbitration agreement clearly communicated that the right to rescind within 30 days could be requested verbally or in writing. Additionally, the facility failed to ensure the arbitration agreement stated that, with each new admission more than 30 days after discharge, a new arbitration agreement would be offered. The deficient practice has the potential to affect all residents admitted to the facility. The census was 82.Findings included: Record review of the facility Arbitration Agreement revealed the following bullet: 9. […]

• No harm, potential for more than minimal, widespreadF880Aug 13, 2026

  Based on record review and staff interviews, the facility failed to implement an effective water management program to minimize the risk of Legionella (a bacterium that grows in warm water (77-113 F) and can multiply in building water systems). The facility established hot water control limits between 100-116 F, a range that supports Legionella growth, but failed to document corrective actions when hot water temperatures measured within this range. The facility also established a cold water control limit of 68 F but failed to monitor or document cold water temperatures. Although a written water management plan was provided, the facility did not demonstrate implementation of required monitoring or corrective actions. […]

• No harm, potential for more than minimal, widespreadF803Nov 21, 2022

  Based on observations, record review, resident interview and staff interviews, the facility failed to follow the prepared menu for 3 out of 4 meals observed when food items were substituted or omitted, but not noted or updated on the menu in advance time. Findings included: 1. The menu provided titled Fall/Winter 2022-2023 Week 3 revealed the lunch on 11/16/22 was homemade vegetable soup, saltine crackers, grilled cheese sandwich, vegetable sticks, and chilled peaches. A review of a handwritten menu dated 11/16/22 at 9:30 AM which posted at the nurses' station on 11/16/22 revealed a pimento cheese sandwich instead of grilled cheese sandwich. Observation of the lunch meal on 11/16/22 at 12:30 PM revealed a cold pimento cheese sandwich was served instead of grilled cheese sandwich. […]

• No harm, potential for more than minimal, widespreadF812Nov 21, 2022

  Based on observations and staff interviews, the facility failed to discard leftover food stored ready for use past the use dates and failed to label, date, and seal a leftover food item stored in 1 of 1 walk-in refrigerator. These practices had the potential to affect food served to residents. Findings included: During the initial kitchen tour of the walk-in refrigerator on 11/15/22 at 10:05 AM the following concerns were observed: - a container labeled vanilla pudding with an opened date of 11/04/22 and a use by date by 11/08/22 - a container labeled [NAME] and beans with an opened date of 11/07/22 and use by date by 11/13/22, and - a container labeled apple sauce had no opened date, and a use by date of 11/13/22 - a package of exposed ham which was unwrapped, and the expiration date… […]

• No harm, potential for more than minimal, widespreadF867Nov 21, 2022

  Based on observations, record review and staff interviews the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to maintain implemented procedures and monitor the interventions that the committee put into place following the recertification and complaint investigation survey on 07/30/21 and the recertification survey on 01/09/20. This was for two deficiencies that were originally cited in July 2021 in the areas of infection control and competent nursing staff and for one deficiency originally cited in January 2020 for food procurement, storage, and sanitation and were subsequently recited on the current recertification survey of 11/21/22. […]