Provider Name: LIBERTY COMMONS
Address: 390 ORLEANS ROAD, NORTH CHATHAM, MA 02650
Phone: (508) 945-4611
County: Barnstable (000)
Ownership Type: For profit - Corporation
Certified Beds: 132
Average Residents Per Day: 113. ()
Provider Type: Medicare and Medicaid, Resides in Hospital: No
Legal Business Name: BROAD REACH OF CHATHAM INC
First Approved Date: February 2, 1989
Affiliated Entity: ()
Retirement Community: N, Special Focus Status:
Ownership Change in Last 12 Months: N
Resident Family Council: Resident
Sprinkler System Status: Yes
Overall Rating: 5 ()
Health Inspection Rating: 4 ()
QM Rating: 5 ()
Long Stay QM Rating: 5 ()
Short Stay QM Rating: 5 ()
Staffing Rating: 5 ()
Staffing Report Note:
PT Staffing Note:
Nurse Aide Staff Hours Per Day, per resident: 2.28791, LPN Staff Hours Per Day: 0.8174, RN Staff Hours Per Day: 0.7930, Licensed Staff Hours Per Day: 1.6105
Total Nurse Staff Hours Per Day, per resident: 3.89848
Weekend Nurse Staff Hours: 3.31870, Weekend RN Staff Hours: 0.5278
PT Staff Hours Per Day, per resident: 0.1360
Nurse Staff Turnover: 32.6, Nurse Turnover Note:
RN Turnover: 11.1, RN Turnover Note:
Admin Left Number: 0, Admin Turnover Note:
Case Mix Nurse Aide Hours Per Day, per resident: 2.0121, Case Mix LPN Hours Per Day: 0.6428, Case Mix RN Hours Per Day: 0.2870
Adjusted Nurse Aide Hours Per Day, per resident: 2.31644, Adjusted LPN Hours Per Day: 0.9384, Adjusted RN Hours Per Day: 1.0412
Total Adjusted Nurse Hours Per Day, per resident: 4.17681
Adjusted Weekend Nurse Hours Per Day, per resident: 3.55564
Health Survey Dates and Scores: Cycle 1: 2020-10-27 (Score: 32), Cycle 2: 2019-02-19 (Score: 44), Cycle 3: 2017-11-08 (Score: 0)
Total Weighted Health Score: 30.667
Reported Incidents: 0, Substantiated Complaints: 1
Infection Control Citations:
Fines and Penalties: Number of Fines: 1, Total Fines in Dollars: 8648.25, Payment Denials Number: 0, Total Penalties Number: 1
Location and GPS: 390 ORLEANS ROAD,NORTH CHATHAM,MA,02650 (41.7005, -69.966)
Process Date: 2024-03-01
Each record details specific health deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:
Type: Health, Deficiency: Allow residents to self-administer drugs if determined clinically appropriate.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2020-11-20
Type: Health, Deficiency: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2020-11-20
Type: Health, Deficiency: Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Severity: G - Level 3: Actual harm that is not immediate jeopardy. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2020-11-20
Type: Health, Deficiency: Ensure 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.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2020-11-20
Type: Health, Deficiency: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Severity: G - Level 3: Actual harm that is not immediate jeopardy. Plan of Correction required.
Corrected: Past Non-Compliance on 2022-04-04
Type: Health, Deficiency: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-03-30
Type: Health, Deficiency: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-03-30
Type: Health, Deficiency: Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-03-30
Type: Health, Deficiency: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-03-30
Type: Health, Deficiency: Implement 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.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-03-30
Type: Health, Deficiency: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.
Corrected: Deficient, Provider has date of correction on 2019-03-30
Each record details specific fire safety deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications: