Liberty Commons Nursing & Rehabilitation Center

DPASARR screening for Mental disorders or Intellectual Disabilities

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0645 · Deficient, Provider has date of correction (Aug 12, 2024)

DProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0690 · Complaint inspection · Deficient, Provider has date of correction (Aug 12, 2024)

DProvide safe and appropriate respiratory care for a resident when needed.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0695 · Deficient, Provider has date of correction (Aug 12, 2024)

DProvide safe, appropriate dialysis care/services for a resident who requires such services.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0698 · Deficient, Provider has date of correction (Aug 12, 2024)

DProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0755 · Complaint inspection · Deficient, Provider has date of correction (Aug 12, 2024)

DImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0758 · Deficient, Provider has date of correction (Aug 12, 2024)

ESafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0842 · Complaint inspection · Deficient, Provider has date of correction (May 10, 2024)

ESet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Potential for more than minimal harm · Administration Deficiencies · Tag F0867 · Complaint inspection · Deficient, Provider has date of correction (May 10, 2024)

DProvide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.

Potential for more than minimal harm · Administration Deficiencies · Tag F0776 · Complaint inspection · Past Non-Compliance (Mar 19, 2024)

EConduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Potential for more than minimal harm · Administration Deficiencies · Tag F0944 · Complaint inspection · Deficient, Provider has date of correction (Dec 21, 2023)

DHonor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0557 · Complaint inspection · Past Non-Compliance (Nov 3, 2023)

DProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0755 · Complaint inspection · Deficient, Provider has date of correction (Dec 21, 2023)

DSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Potential for more than minimal harm · Administration Deficiencies · Tag F0867 · Complaint inspection · Deficient, Provider has date of correction (Dec 21, 2023)

FProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0812 · Deficient, Provider has date of correction (Jun 6, 2023)

FSet up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Potential for more than minimal harm · Administration Deficiencies · Tag F0867 · Deficient, Provider has date of correction (Jun 6, 2023)

FProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Deficient, Provider has date of correction (Jun 6, 2023)

EEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0756 · Deficient, Provider has date of correction (Jun 6, 2023)

EEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0761 · Deficient, Provider has date of correction (Jun 6, 2023)

EDispose of garbage and refuse properly.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0814 · Deficient, Provider has date of correction (Jun 6, 2023)

DAssure that each resident’s assessment is updated at least once every 3 months.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0638 · Deficient, Provider has date of correction (Jun 6, 2023)

DCreate and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0655 · Deficient, Provider has date of correction (Jun 6, 2023)

DDevelop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0657 · Deficient, Provider has date of correction (Jun 6, 2023)

DProvide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0690 · Deficient, Provider has date of correction (Jun 6, 2023)

DProvide enough food/fluids to maintain a resident's health.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0692 · Deficient, Provider has date of correction (Jun 6, 2023)

DEnsure each resident’s drug regimen must be free from unnecessary drugs.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0757 · Deficient, Provider has date of correction (Jun 6, 2023)

DImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0758 · Deficient, Provider has date of correction (Jun 6, 2023)

DEnsure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0806 · Deficient, Provider has date of correction (Jun 6, 2023)