Liberty Commons Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Jul 15, 2022

  Based on record review, police report and interviews with the resident, staff and nurse practitioner interview the facility failed to ensure a resident was free of staff to resident physical abuse for 1 of 3 residents reviewed for allegations of abuse (Resident #69). Resident #69 had bruises on her right arm and right forehead as well as a laceration to the bridge of her nose. The findings included: Resident #69 was admitted to the facility on [DATE]. Resident #69 ' s significant change Minimum Data Set assessment dated [DATE] revealed she was assessed as having a moderate cognitive impairment. She was assessed to have adequate hearing, clear speech and was able to make herself understood by others. She had no behaviors during the lookback period. […]

• Actual harm, isolatedF550Mar 18, 2026

  Based on record review and interviews with staff, Emergency Medical Services (EMS) personnel, and pest control specialist, the facility failed to ensure a resident's dignity was maintained when Resident #86 was observed by EMS personnel with multiple live cockroaches crawling on his body and in his bed prior to transferring the resident to the hospital. EMS personnel indicated the resident was not aware of the cockroaches. A reasonable person expects their dignity to be maintained by their caregivers and would have been traumatized and experienced feelings such as fear, dehumanization, humiliation, and anxiety. […]

• Actual harm, isolatedF760Jan 22, 2025

  Based on record review, staff, Physician, and the Consultant Pharmacist interviews the facility failed to prevent significant medication errors by administering Resident #223 the incorrect dose of a blood pressure medication, Losartan 50 milligrams (an antihypertensive), and administering blood pressure medications without following the physician's ordered parameters to hold the medication (Residents #223 and #47). This resulted in Resident #223 experiencing hypotension (low blood pressure) and symptoms of head pressure, neck pain, and nausea. There was no significant outcome for Resident #47. This deficient practice occurred for 2 of 2 residents reviewed for medication administration. […]

• Actual harm, isolatedF689Nov 2, 2023

  Based on record review and staff and resident interviews the facility failed to notify the nurse when a resident refused to be transferred with a mechanical lift and two nurse aides decided to transfer the resident (Resident #2) by manually lifting the resident from the bed to the shower bed causing her to fracture her tibia for 1 of 4 residents reviewed for accidents. Findings included: Resident #2 was admitted to the facility on [DATE]. Diagnoses included cerebral palsy (spastic paralysis causing impaired muscle coordination), osteoporosis (brittle and fragile bones), anxiety, vitamin D deficiency, contractures to left elbow and left wrist, and fracture of shaft of right tibia. […]

• Actual harm, isolatedF835Jul 15, 2022

  Based on record review, observation, and interviews with resident representative and staff, the facility failed to provide effective leadership and oversight to ensure systems and policies were implemented related to COVID-19 staff vaccinations for 3 of 3 dietary staff (Dietary Aide #1, Dietary Aide #2, and Dietary Aide #3), resident vaccinations for 1 of 5 residents (Resident #39), and staff testing for 3 of 3 unvaccinated staff (Nurse #3, Nurse Aide #3 and Housekeeper #1). The facility was in COVID-19 outbreak status and had 18 residents test positive for COVID-19 since 6/15/22 (Resident #31, Resident #64, Resident #21, Resident#1, Resident #17, Resident #40, Resident #35, Resident #270, Resident #5, Resident #38, Resident #24, Resident #54, Resident #3, Resident #36, Resident #39,… […]