LIBERTY COMMONS N&R ALAMANCE

Nursing Home Inspector

791 BOONE STATION DRIVE
BURLINGTON, NC 27215
Alamance County
Phone: 336-586-9850
Provider Number: 345496
Last Inspection: 10/13/2017

About the Nursing Home

Number of Beds: 90
Number of Residents: 80
Beds Available: 10
Percent Occupancy: 89%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: For profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

4

Facility
12

County
14

NC
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

4

2017
34

2016
25

2016

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

10/13/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Store, cook, and serve food in a safe and clean way. Pattern : Minimal 4 11/10/2017
 

10/28/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure services provided by the nursing facility meet professional standards of quality. Isolated : Minimal 3 11/25/2016
 
Failed To: Send unopened mail from residents and promptly deliver unopened mail to residents. Widespread : Potential 4 11/25/2016
 
Failed To: Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. Pattern : Minimal 4 11/25/2016
 
Failed To: Listen to the resident groups and act on their complaints and suggestions that affect resident care and life. Pattern : Minimal 4 11/25/2016
 
Failed To: Provide housekeeping and maintenance services. Pattern : Minimal 4 11/25/2016
 
Failed To: Have enough nurses to care for every resident in a way that maximizes the resident's well being. Pattern : Minimal 4 11/25/2016
 
Failed To: Post nurse staffing information/data on a daily basis. Widespread : Potential 4 11/25/2016
 
Failed To: Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. Pattern : Minimal 4 11/25/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Minimal 3 11/25/2016
 

3/31/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. Isolated : Minimal 3 4/25/2016
 
Failed To: Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. Isolated : Minimal 3 4/25/2016
 
Failed To: Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. Pattern : Potential 3 4/6/2016
 
Failed To: Upon the death of a resident, convey the resident’s personal funds and an accounting of those funds to the appropriate party. Widespread : Potential 4 4/5/2016
 
Failed To: Keep each resident free from physical restraints, unless needed for medical treatment. Isolated : Minimal 3 4/25/2016
 
Failed To: Assess in a timely manner the resident when the resident enters the nursing home. Isolated : Minimal 3 4/25/2016
 
Failed To: Review or revise the resident's care plan after any major change in physical or mental health. Isolated : Minimal 3 4/25/2016
 
Failed To: Assure that each resident’s assessment is updated at least once every 3 months. Isolated : Minimal 3 4/25/2016
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

4/6/2017 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 5/3/2017
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Isolated : Minimal 3 5/3/2017
 

6/14/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. Isolated : Minimal 3 6/26/2016
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg NC State Avg
Number of Residents 80 97.50 84.96
Registered Nurses 0.48 0.82 0.72
Licensed Practical / Vocational Nurses 0.74 0.74 0.87
Certified Nursing Assistants 2.23 2.60 2.33
Total Staff Hours 3.44 4.16 3.91

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% NC State Avg%
of high risk long-stay residents with pressure ulcers 2 4 7
of long-stay residents assessed and appropriately given the pneumococcal vaccine 99 95 93
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 99 96 93
of long-stay residents experiencing one or more falls with major injury 1 3 3
of long-stay residents who have depressive symptoms 0 1 2
of long-stay residents who lose too much weight 5 9 8
of long-stay residents who received an antianxiety or hypnotic medication 22 28 29
of long-stay residents who received an antipsychotic medication 24 18 13
of long-stay residents who self-report moderate to severe pain 14 6 6
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 30 22 23
of long-stay residents whose need for help with daily activities has increased 23 20 18
of long-stay residents with a catheter inserted and left in their bladder 2 1 1
of long-stay residents with a urinary tract infection 9 4 4
of low risk long-stay residents who lose control of their bowels or bladder 82 63 55
of short-stay residents assessed and appropriately given the pneumococcal vaccine 94 88 83
of short-stay residents who had an outpatient emergency department visit 12 11 13
of short-stay residents who made improvements in function 69 64 64
of short-stay residents who newly received an antipsychotic medication 1 1 1
of short-stay residents who self-report moderate to severe pain 31 17 14
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 93 89 81
of short-stay residents who were rehospitalized after a nursing home admission 27 20 20
of short-stay residents who were successfully discharged to the community 61 59 55
of short-stay residents with pressure ulcers that are new or worsened 1 0 0