Health inspection·August 28, 2019

F 0640 Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, Centers for Medicaid and Medicare Services (CMS) Submission Report review, policy review and staff interview, the facility failed to submit the annual Minimum Data Set (MDS) assessment within the 14 days after completion of assessments. This affected two Residents (#1 and #2) out of two reviewed for resident assessment. The facility census was 71. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #2 revealed an admission date of 07/13/18, with diagnoses including methicillin resistant staphylococcus aureus (mrsa) infection, sepsis, cellulitis, urinary tract infection, metabolic encephalopathy, gastro-esophageal reflux disease, neuromuscular dysfunction of bladder, diabetes, morbid obesity, depression, restless legs syndrome, obstructive sleep apnea, hypertension, congestive heart failure, chronic obstructive pulmonary disease, osteoarthritis, chronic gout, acute kidney failure, altered mental status, and enterocolitis. Review of the Annual MDS dated [DATE] revealed Resident #2 has no cognitive deficits, requires supervision with activities of daily living (adl), is frequently incontinent of bladder, and always continent of bowel. Review of CMS Submission Report dated 08/21/19 revealed that Resident's #2 target date was 07/18/19 and was submitted late on 08/21/19 at 9:01 A.M. Interview on 08/27/19 at 8:55 A.M. with Registered Nurse (RN) #30 verified that the MDS was submitted more than 14 days late. 2. Review of the medical record for Resident #1 revealed an admission date of 11/27/17, with diagnoses including Parkinson disease, hypercholesterolemia, gastro-esophageal reflux disease, osteoporosis, vitamin D deficiency, hypertension, constipation, muscle weakness, wedge compression fracture, Alzheimer's, depression, left hip fracture, and open-angle glaucoma. Review of Annual MDS dated [DATE] revealed Resident #1 has mild cognitive deficits, requires extensive assist with most adl's, is frequently incontinent of bladder, and occasionally incontinent of bowel. Review of the CMS Submission Report date 08/27/19 revealed that Resident's #1 target date was 07/16/19 and was submitted late on 08/27/19 at 9:11 P.M. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 5 Event ID: 366427 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 366427 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/28/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Liberty Nursing Center of Colerain Inc 8440 Livingston Road Cincinnati, OH 45247 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)