Liberty Healthcare Services of Golden Years Nursin

In the surveyor’s words

From the most serious findings on record at Liberty Healthcare Services of Golden Years Nursin, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF641Mar 18, 2022

  Based on record review and staff interviews the facility failed to accurately code the Minimum Data Set (MDS) to reflect the Preadmission Screening and Resident Review (PASRR) Level II status for 3 of 4 residents (Resident #16, #19, and #29) and to correctly code a resident's personal hygiene on a quarterly minimum data set assessent (Resident #23) for 4 of 4 residents reviewed for MDS accuracy. Finding included: 1. The North Carolina Department of Health and Human Services PASRR Level II determination notification dated 08/10/2021 revealed the nursing facility placement was appropriate. Resident #16 was admitted to the facility on [DATE] with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] #16 coded as cognitively intact and needed extensive assistance with activities of daily living (ADL). […]

• No harm, potential for more than minimal, isolatedF641Nov 20, 2025

  Based on medical record review and staff interviews, the facility failed to accurately code the Quarterly Minimum Data Set (MDS) assessment for 1 of 33 sampled residents reviewed for diagnosis of depression. (Resident #12)Findings included:Resident #12 was admitted to the facility on [DATE]. Cumulative diagnoses included hypertension, diabetes mellitus, depression and hyperlipidemia.Review of the August 2025 Medication Administration Record (MAR) revealed Resident #12 received the medication Sertraline (antidepressant medication) tablet 25 Milligram (MG) 1 tablet by mouth one time a day for depression.Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] indicated Resident #12 was cognitively intact. […]

• No harm, potential for more than minimal, isolatedF677Mar 10, 2025

  Based on record review, observations, and interviews of staff and residents, the facility failed to provide nail care for dependent residents (Resident #s 2, 3, 4, 6, and 7). This deficient practice affected 5 of 6 residents reviewed for activity of daily living. Findings included: 1. Resident #2 was admitted to the facility on [DATE] with the diagnosis of chronic obstructive pulmonary disease. Resident #2's care plan dated 2/3/25 documented the resident had an activity of living self-care performance deficit. The intervention was to check nail length and trim as necessary. There was no refusal of care in the plan. The quarterly Minimum Data Set, dated dated dated [DATE] for Resident #2 documented he had a severly impaired cognition. […]

• No harm, potential for more than minimal, isolatedF645Aug 29, 2024

  Based on staff interviews and record reviews the facility failed to apply for an updated level I Preadmission Screening and Resident Review (PASRR) for a resident admitted with mental health diagnoses for 1 of 3 residents reviewed for PASRR (Resident #36). The findings included: A review of the medical record for Resident #36 was admitted into the facility on [DATE] with diagnoses that included major depression and psychotic disorder. A review of Resident #36's most recent PASRR Level I screen was dated 11/16/21 and marked no to the question is there a Mental Health diagnosis. […]

• No harm, potential for more than minimal, isolatedF641Aug 3, 2023

  Based on record review and staff interviews the facility failed to accurately code the Minimum Data Set (MDS) assessment in the areas of discharge location (Resident #42) and tracheostomy care (Resident #145) for 2 of 12 residents reviewed for MDS accuracy. The findings included: 1. Resident #145 was admitted to the facility on [DATE] with diagnoses that inclued laryngectomy (surgical removal of the larnyx) and tracheostomy (a breathing tube). The 5-day Minimum Data Set (MDS) dated [DATE] had Resident #145 was moderately cognitively. He was coded for suctioning and as not having a tracheostomy. The care plan dated 10/11/2022 had a focus of laryngectomy, tracheal suctioning as needed (PRN) for congestion or unable to clear secretions, change tracheostomy ties weekly and PRN. […]