Liberty Retirement Community of Lima

FConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Potential for more than minimal harm · Administration Deficiencies · Tag F0838 · Deficient, Provider has date of correction (Apr 10, 2026)

FProvide and implement an infection prevention and control program.

Potential for more than minimal harm · Infection Control Deficiencies · Tag F0880 · Complaint inspection · Deficient, Provider has date of correction (Apr 10, 2026)

EHonor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0584 · Complaint inspection · Deficient, Provider has date of correction (Apr 10, 2026)

EEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0689 · Complaint inspection · Deficient, Provider has date of correction (Apr 10, 2026)

EProvide 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 (Apr 10, 2026)

DImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0580 · Complaint inspection · Deficient, Provider has date of correction (Apr 10, 2026)

DEnsure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Potential for more than minimal harm · Freedom from Abuse, Neglect, and Exploitation Deficiencies · Tag F0604 · Complaint inspection · Deficient, Provider has date of correction (Apr 10, 2026)

DEnsure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0627 · Deficient, Provider has date of correction (Apr 10, 2026)

DProvide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0628 · Deficient, Provider has date of correction (Apr 10, 2026)

DDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Potential for more than minimal harm · Resident Assessment and Care Planning Deficiencies · Tag F0656 · Complaint inspection · Deficient, Provider has date of correction (Apr 10, 2026)

DProvide activities to meet all resident's needs.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0679 · Complaint inspection · Deficient, Provider has date of correction (Apr 10, 2026)

DProvide appropriate treatment and care according to orders, resident’s preferences and goals.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0684 · Complaint inspection · Deficient, Provider has date of correction (Apr 10, 2026)

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 (Apr 10, 2026)

DEnsure that the resident and his/her doctor meet face-to-face at all required visits.

Potential for more than minimal harm · Nursing and Physician Services Deficiencies · Tag F0712 · Deficient, Provider has date of correction (Apr 10, 2026)

DEnsure 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 (Apr 10, 2026)

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 (Apr 10, 2026)

DEnsure that residents are free from significant medication errors.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0760 · Complaint inspection · Deficient, Provider has date of correction (Apr 10, 2026)

DEnsure 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 (Apr 10, 2026)

DProvide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.

Potential for more than minimal harm · Administration Deficiencies · Tag F0773 · Complaint inspection · Deficient, Provider has date of correction (Apr 10, 2026)

DProvide or obtain dental services for each resident.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0791 · Deficient, Provider has date of correction (Apr 10, 2026)

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 (Apr 10, 2026)

DProvide special eating equipment and utensils for residents who need them and appropriate assistance.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0810 · Deficient, Provider has date of correction (Apr 10, 2026)

DProvide appropriate pressure ulcer care and prevent new ulcers from developing.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0686 · Complaint inspection · Deficient, Provider has date of correction (Feb 17, 2025)

DEnsure that residents are free from significant medication errors.

Potential for more than minimal harm · Pharmacy Service Deficiencies · Tag F0760 · Complaint inspection · Deficient, Provider has date of correction (Feb 17, 2025)

DHonor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0561 · Complaint inspection · Deficient, Provider has date of correction (Dec 31, 2024)

DProvide appropriate treatment and care according to orders, resident’s preferences and goals.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0684 · Complaint inspection · Deficient, Provider has date of correction (Aug 1, 2024)

DProvide appropriate pressure ulcer care and prevent new ulcers from developing.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0686 · Complaint inspection · Deficient, Provider has date of correction (Aug 1, 2024)

FEmploy sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0801 · Deficient, Provider has date of correction (Jun 10, 2024)

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 · Complaint inspection · Deficient, Provider has date of correction (Jun 10, 2024)

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 10, 2024)

FHave enough outside ventilation via a window or mechanical ventilation, or both.

Potential for more than minimal harm · Environmental Deficiencies · Tag F0923 · Complaint inspection · Deficient, Provider has date of correction (Jun 10, 2024)

EHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0550 · Deficient, Provider has date of correction (Jun 10, 2024)

EProvide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0744 · Complaint inspection · Deficient, Provider has date of correction (Jun 10, 2024)

EEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0803 · Deficient, Provider has date of correction (Jun 10, 2024)

DReasonably accommodate the needs and preferences of each resident.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0558 · Deficient, Provider has date of correction (Jun 10, 2024)

DHonor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0578 · Deficient, Provider has date of correction (Jun 10, 2024)

DProvide appropriate pressure ulcer care and prevent new ulcers from developing.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0686 · Deficient, Provider has date of correction (Jun 10, 2024)

DEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0689 · Deficient, Provider has date of correction (Jun 10, 2024)

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 10, 2024)

DHave an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided.

Potential for more than minimal harm · Administration Deficiencies · Tag F0772 · Deficient, Provider has date of correction (Jun 10, 2024)

DEnsure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Potential for more than minimal harm · Nutrition and Dietary Deficiencies · Tag F0805 · Deficient, Provider has date of correction (Jun 10, 2024)

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 · Complaint inspection · Deficient, Provider has date of correction (Jan 16, 2024)

EEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0689 · Deficient, Provider has date of correction (Jun 1, 2023)

DReasonably accommodate the needs and preferences of each resident.

Potential for more than minimal harm · Resident Rights Deficiencies · Tag F0558 · Deficient, Provider has date of correction (Jun 1, 2023)

DProvide appropriate foot care.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0687 · Deficient, Provider has date of correction (Jun 1, 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 1, 2023)

DProvide timely, quality laboratory services/tests to meet the needs of residents.

Potential for more than minimal harm · Administration Deficiencies · Tag F0770 · Deficient, Provider has date of correction (Jun 1, 2023)

DProvide or get specialized rehabilitative services as required for a resident.

Potential for more than minimal harm · Quality of Life and Care Deficiencies · Tag F0825 · Deficient, Provider has date of correction (Jun 1, 2023)