Liberty Ridge Health & Rehab

In the surveyor’s words

From the most serious findings on record at Liberty Ridge Health & Rehab, in the surveyor’s own words.

• Actual harm, isolatedF658Jun 5, 2024

  Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to follow professional standards of practice during medication administration, that resulted in harm for 1 of 21 residents in the survey sample. (Resident # 33 - R 33). The findings include: Facility staff administered medications to R33 that had been ordered for another resident, R15, who was her roommate. The nurse that prepared the medications gave the medication to another nurse to administer, which resulted in R33 receiving medications not intended or ordered for her, requiring hospitalization , which is harm. On 6/4/24 and 6/5/24, a clinical record review was conducted of R33's chart. […]

• Actual harm, isolatedF760Jun 5, 2024

  Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to ensure that 1 of 21 residents in the survey sample were free of significant medication errors, which resulted in harm (Resident # 33 - R 33). The findings include: Facility staff administered medications to R33 that had been ordered for another resident, R15, who was the roommate. The nurse that prepared the medications gave the medication to another nurse to administer, which resulted in R33 receiving medications not intended or ordered for her. resulting in hospitalization , which caused harm. […]

• No harm, potential for more than minimal, patternF803Jun 5, 2024

  Based on observation, resident and staff interviews, and facility documentation review, the facility staff failed to follow the posted menu, affecting residents on 2 of 2 nursing units. The findings included: The facility staff failed to follow the posted menu with regards to the vegetable. On 6/3/24 at 3 p.m., the resident council met with a surveyor. During the meeting, residents verbalized that they do not get what is posted on the menu. On 6/3/24 at approximately 4 p.m., observations were made of the menu posting on each of the resident units. The evening meal was listed as chicken tenders, greens, and macaroni and cheese. […]

• No harm, potential for more than minimal, patternF804Jun 5, 2024

  Based on observations, resident and staff interviews, and facility documentation review, the facility failed to provide foods that were at appetizing temperatures on two of two nursing units, affecting multiple residents. Findings include: The facility staff failed to serve foods at an appetizing temperature on the long-term care unit. On 6/3/24 at 3 p.m., a meeting was held with the resident council, of which seven residents were in attendance. During the meeting, the residents verbalized that the food is not hot. On 6/3/24 at 3:15 p.m., an interview was conducted with Resident #51 (R51) who stated, The food is lukewarm, coffee is not hot. […]

• No harm, potential for more than minimal, patternF812Jun 5, 2024

  Based on observation, staff interview, and facility documentation review, the facility staff failed to store and prepare food in accordance with food safety standards in the main kitchen having the potential to affect residents on 2 of 2 resident care units. The findings included: 1. The facility staff failed to store foods in a manner to prevent contamination and failed to label and date items in the freezer and refrigerators. On [DATE] at 10:35 a.m., an initial tour of the kitchen was conducted with the dietary manger. This observation revealed that in the dry storage room there was two bags of pasta that were open to air. One bag of pasta had the bag tied but a hole had also been ripped into the bag. Neither bag was dated as to when they were opened. […]