Liberty Commons Nursing & Rehabilitation Center of

In the surveyor’s words

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

• Immediate jeopardy, isolatedF580Dec 8, 2023

  Based on observation, record review, resident, staff, paramedic, and physician interview the facility failed to notify the physician regarding a significant change in condition for one (Resident # 3) of two sampled residents. On the morning of 9/27/23 Nurse Aide #1 and Nurse #3 observed signs Resident # 3 was experiencing a significant change in condition including a low blood pressure, slurred speech, sluggishness, inability to carry on a conversation per his norm, inability to help in his care per his norm, and bloody urine in his catheter. The physician was not notified when staff noted the change in condition. […]

• Immediate jeopardy, isolatedF684Dec 8, 2023

  Based on observation, record review, resident, staff, paramedic, and physician interview the facility failed to effectively assess and address a significant change in condition for one (Resident # 3) of two sampled residents whose condition necessitated Emergency Medical Services (EMS) to be called. Resident # 3 had a history of sepsis (when an infection triggers widespread inflammation in a person's body which can lead to organ damage) and on the morning of 9/27/23 Nurse Aide #1 and Nurse #3 observed Resident # 3 was experiencing a change in condition prior to the lunch meal that included: a low blood pressure, slurred speech, sluggishness, inability to carry on a conversation per his norm, inability to help in his care per his norm, and bloody urine in his catheter. […]

• Immediate jeopardy, isolatedF600Jun 2, 2023

  Based on observation, record review, resident interviews, and staff interviews the facility failed to protect the rights of two residents (Resident # 5 and Resident # 6) to be free of abuse. Following a verbal altercation, Resident # 6, who was cognitively intact, reported feeling threatened by Resident # 5, who was cognitively impaired. Resident # 6 and Resident # 5 then became involved in a physical fight during which Resident # 6 held Resident # 5 down on his bed by Resident # 5's neck and hit him multiple times in the face. Resident # 5 sustained scratches to his neck and finger. This was for two of three sampled residents reviewed for abuse. The findings included: Record review revealed Resident # 5 was admitted to the facility on [DATE]. […]

• Immediate jeopardy, isolatedF600Feb 25, 2022

  Based on record review, resident, and staff interview, the facility failed to protect 1 of 1 resident (Resident #65) from employee to resident physical abuse. On 12-24-21 while providing care to Resident #65 Nursing Assistant (NA) #1 grabbed onto his right arm, jerked his arm and slapped his face resulting in the bridge of Resident #65's nose bleeding and bruising to his right upper and lower arm. Immediate Jeopardy began on 12-24-21 when the facility failed to protect Resident #65 from employee to resident physical abuse. Immediate Jeopardy was removed on 2-25-22 when the facility implemented an acceptable credible allegation on Immediate Jeopardy removal. […]

• Immediate jeopardy, isolatedF607Feb 25, 2022

  Based on record review, staff and Physician interview, the facility failed to follow their abuse policy to implement interventions to protect residents from physical abuse. On 12-24-21 at approximately 5:30am Nursing Assistant (NA) #1 grabbed Resident #65's right arm, jerked his arm and slapped his face resulting in the bridge of Resident #65's nose bleeding and bruising to his right upper and lower arm. NA #1 was allowed to complete her shift and continue to provide care to other residents following the incident. The facility also failed to implement their abuse policy in the areas of reporting and investigating abuse. […]