Liberty Station Health Campus

In the surveyor’s words

From the most serious findings on record at Liberty Station Health Campus, in the surveyor’s own words.

• Actual harm, isolatedF689Jun 25, 2026

  THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on record review, staff interview, hospital record review, policy review and review of the facility investigation documents, the facility failed to provide assistance with bed mobility during incontinence care resulting in a resident falling out of bed and sustaining injuries. This resulted in Actual Harm on 04/14/26 when Certified Nursing Assistant (CNA) #110 was providing personal care to Resident #52 without the appropriate level assistance. She rolled the resident away from her in the bed resulting in Resident #52 rolling off the bed onto the floor. […]

• No harm, potential for more than minimal, widespreadF812Jun 25, 2026

  Based on observation, interviews, and facility policy the facility failed to provide sanitary storage and preparation of food. This had the potential to affect all residents. The facility census was 38. Findings include:Observation of then kitchen on 06/23/26 at 12:27 P.M. with [NAME] #124, revealed she was cooking a hamburger on the grill. Her hair net was only covering the top of her head and there was hair hanging out around the hair net. Interview with [NAME] #124 at the same time, verified her hair net was not covering all her hair. Observation of then kitchen on 06/22/26 at 9:16 A.M. with Dietary Manager (DM) #319 revealed in the walk-in freezer there was an opened box where the plastic bag that was ripped open with hash brown patties inside and exposed and not labeled. […]

• No harm, potential for more than minimal, widespreadF814Jun 25, 2026

  Based on record review, observation, staff interviews, and review of facility policy, the facility failed to ensure that refuge in the kitchen was properly covered. This had the potential to affect all 38 residents who received food from the facility. The facility census was 38. Findings include:Observation of the kitchen on 06/22/26 at 9:21 A.M. with Dietary Manager (DM) #139, revealed a large 55-gallon trash can next to the over containing trash and no lid in place. Interview with DM #319 at the same time, verified the large 55-gallon trash with no lid in place . Observation of the kitchen on 06/23/26 at 11:52 A.M. with DM #139 revealed staff were prepping and cooking food for the lunch meal. […]

• No harm, potential for more than minimal, isolatedF637Jun 25, 2026

  Based on medical record reviews, staff interview, and review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to complete significant change Minimum Data Set (MDS) assessments timely. This affected two Residents (#04 and #35) out of three residents reviewed for Hospice services. The facility census was 38.Findings include: 1) Review of the medical record for Resident #04 revealed an admission date of 05/04/25 with medical diagnoses of metabolic encephalopathy, asthma, atrial fibrillation, congestive heart failure (CHF) and hypertensive heart disease with heart failure. Review of Resident #04's physician orders revealed an order dated 05/15/26 for Hospice services for terminal diagnosis of CHF. […]

• No harm, potential for more than minimal, isolatedF677Jun 25, 2026

  Based on record review, observations, staff interviews, and review of resident rights policy, the facility failed to meet grooming needs for two Residents (#34 and #20) out of five residents reviewed for activities of daily living (ADL). The facility census was 38. 1) Review of medical record for Resident #34 revealed an admission date 4/01/26. Diagnoses included malignant neoplasm of bladder, type two diabetes, and benign neoplasm of prostate. Review of admission Minimum Data Set (MDS) dated [DATE] revealed Resident #34 had a Brief Interview Mental Status (BIMS) of 11 indicating the resident was moderately cognitively impaired. Resident #34 was dependent on staff for all ADLs. […]