Liberty Health Care Center Inc

In the surveyor’s words

From the most serious findings on record at Liberty Health Care Center Inc, in the surveyor’s own words.

• Actual harm, isolatedF686Sep 16, 2025

  Based on closed record review, interview and facility policy review, the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to prevent, accurately and timely assess, promote healing and prevent pressure ulcer/wound infection from occurring. This affected one (Resident #95) of three residents reviewed for pressure ulcers. The facility census was 93. Actual Harm occurred on 07/03/25 when Resident #95 was assessed to have an acute change in condition requiring hospitalization. Upon hospital assessment, the resident was assessed to have a Stage II pressure ulcer to the sacrum with extensive gas forming soft tissue infection at the lower back extending to the tip of the coccyx measuring 9.0 centimeters (cm) by 2.3 cm by 16.1 cm. […]

• Actual harm, isolatedF600Aug 29, 2024

  THE FOLLWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of video recorded evidence, review of the facility self-reported incident, review of facility policy, observation and interview, the facility failed to ensure Resident #16 was free from humiliation, intimidation and verbal and physical abuse by staff. Using the reasonable person concept, actual harm occurred on 07/14/24 when Resident #16, who was cognitively impaired and dependent on staff for all activities of daily living (ADL), was forcefully rolled onto his right side for incontinence care by State tested Nursing Assistant (STNA) #434 causing Resident #16's face to go into a pillow requiring him to move his head to yell let me… […]

• Actual harm, isolatedF689Feb 8, 2024

  Based on observation, record review, interview, and facility policy review the facility failed to ensure Resident #77 was free of an accident hazard during a staff assisted transfer. Actual Harm occurred on 01/30/24 when Resident #77 suffered a second-degree burn (a burn that involves the first two layers of skin which may present as deep reddening of the skin, pain, blisters, glossy appearance from leaking fluid, and possible loss of some skin) that measured 15 centimeters (cm) in length by 7.5 cm width to her left lower leg from a portable oxygen tank that had been placed on her bed while staff were transporting the resident from her room to the shower room. The improper transport of the oxygen caused the tank to freeze to the resident's leg causing pain/discomfort and the burn. […]

• Actual harm, isolatedF688Apr 3, 2023

  Based on medical record review and interview the facility failed to ensure therapy discharge recommendations were implemented in order to maintain a resident's mobility and range of motion (ROM) capabilities. This affected one (Resident #5) of 24 residents observed for limitations in range of motion. Actual harm occurred on 01/31/23 when Resident #5 presented with limitations in ROM after the facility failed to implement therapy recommendations for restorative nursing programs. Prior to 01/31/23, no ROM impairment had been identified and the resident was noted to be able to ambulate. On 01/31/23 an assessment noted a decrease in range of motion to the resident's right knee and bilateral ankles. […]

• No harm, potential for more than minimal, widespreadF727May 2, 2024

  Based on interview, schedule review, Payroll Based Journal (PBJ) review and Facility Annual Assessment review, that facility failed to ensure there was adequate Registered Nurse (RN) coverage for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 101 residents residing in the facility. Findings include: Review of the PBJ Staffing Data Report CASPER Report 1705D 10/01/23 though 12/31/23 revealed the facility had four or more days within the quarter with no RN coverage and had a one-star staffing rating. […]