A list of the most recent deficiencies for Liberty Health and Wellness. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2023-10-16 | 2023-11-30 | N |
| Provide care or services that was trauma informed and/or culturally competent. | Health | 2023-10-16 | 2023-11-30 | N |
| Post nurse staffing information every day. | Health | 2023-10-16 | 2023-11-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-10-16 | 2023-11-30 | N |
| 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. | Health | 2023-10-16 | 2023-11-30 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2023-10-16 | 2023-11-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-16 | 2023-11-30 | N |
| Honor 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. | Health | 2023-10-16 | 2023-11-30 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-16 | 2023-11-30 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-10-16 | 2023-11-30 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-10-16 | 2023-11-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-16 | 2023-11-30 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-10-16 | 2023-11-30 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-05-04 | 2023-07-14 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-05-04 | 2023-07-14 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-05-04 | 2023-07-14 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-05-04 | 2023-07-14 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2023-05-04 | 2023-07-14 | N |
| Honor 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. | Health | 2023-05-04 | 2023-07-14 | N |
| Honor 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. | Health | 2023-05-04 | 2023-07-14 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-05-04 | 2023-07-14 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-05-04 | 2023-07-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-05-04 | 2023-07-14 | N |
| Provide activities to meet all resident's needs. | Health | 2023-05-04 | 2023-07-14 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-04 | 2023-07-14 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-05-04 | 2023-07-14 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-05-04 | 2023-07-14 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-05-04 | 2023-07-14 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-05-04 | 2023-07-14 | N |
| Ensure 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. | Health | 2023-05-04 | 2023-07-14 | N |
| Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. | Health | 2023-05-04 | 2023-07-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-05-04 | 2023-07-14 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-05-04 | 2023-07-14 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-05-04 | 2023-07-14 | N |
| Provide immediate access to any resident. | Health | 2023-05-04 | 2023-07-14 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-05-04 | 2023-07-14 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-04 | 2023-07-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-04 | 2023-07-14 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-05-04 | 2023-07-14 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-05-04 | 2023-07-14 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-05-04 | 2023-07-14 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-05-04 | 2023-07-14 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-05-04 | 2023-07-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-04 | 2023-07-14 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-05-04 | 2023-07-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-05-04 | 2023-07-14 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-05-04 | 2023-07-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-05-04 | 2023-07-14 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-12-06 | 2023-01-20 | N |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2022-12-06 | 2023-01-20 | N |
| Honor 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. | Health | 2022-12-06 | 2023-01-20 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-12-06 | 2023-01-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-12-06 | 2023-01-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-12-06 | 2023-01-20 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-12-06 | 2023-01-20 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-12-06 | 2023-01-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-12-06 | 2023-01-20 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-12-06 | 2023-01-20 | N |
| Use approved construction type or materials. | Fire Safety | 2022-12-06 | 2023-01-20 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-12-06 | 2023-01-20 | N |
| Have horizontal exits used in accordance with safety requirements. | Fire Safety | 2022-12-06 | 2023-01-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-06 | 2023-01-20 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2022-12-06 | 2023-01-20 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-12-06 | 2023-01-20 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-12-06 | 2023-01-20 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-12-06 | 2023-01-20 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2022-12-06 | 2023-01-20 | N |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2022-09-02 | 2022-09-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-02 | 2022-09-02 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-09-02 | 2022-09-02 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-07-12 | 2022-08-25 | Y |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2022-07-12 | 2022-08-25 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-07-12 | 2022-08-25 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-07-12 | 2022-08-25 | Y |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-07-12 | 2022-08-25 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-07-12 | 2022-08-25 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2022-07-12 | 2022-08-25 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-07-12 | 2022-08-25 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2022-07-12 | 2022-08-25 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-07-12 | 2022-08-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-07-12 | 2022-08-25 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-07-12 | 2022-08-25 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-07-12 | 2022-08-25 | Y |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-07-12 | 2022-08-25 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-07-12 | 2022-08-25 | Y |
| 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. | Health | 2022-07-12 | 2022-08-25 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2022-07-12 | 2022-08-25 | Y |
| Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Health | 2022-07-12 | 2022-08-25 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-07-12 | 2022-08-25 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-02-24 | 2022-03-15 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-01-19 | 2022-03-15 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-01-19 | 2022-03-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-01-19 | 2022-03-15 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-01-19 | 2022-03-15 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-01-19 | 2022-03-15 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-01-19 | 2022-03-15 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-19 | 2022-03-15 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-01-19 | 2022-03-15 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-19 | 2022-03-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-19 | 2022-03-15 | Y |
| Implement a program that monitors antibiotic use. | Health | 2022-01-19 | 2022-03-15 | Y |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-01-19 | 2022-03-15 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-01-19 | 2022-03-15 | Y |
| Report COVID19 data to residents and families. | Health | 2022-01-19 | 2022-03-15 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-01-19 | 2022-03-15 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-11-22 | 2022-03-15 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-11-22 | 2021-11-22 | Y |
| 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. | Health | 2021-11-22 | 2021-11-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-21 | 2021-09-22 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-08-13 | 2021-09-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-13 | 2021-09-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-08-13 | 2021-09-09 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2021-04-19 | 2021-09-09 | Y |
| Honor 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. | Health | 2021-04-19 | 2021-09-09 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-04-19 | 2021-09-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-19 | 2021-09-09 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-04-19 | 2021-09-09 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-04-19 | 2021-09-09 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-04-19 | 2021-09-09 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-04-19 | 2021-09-09 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-06-16 | 2021-08-11 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-04-19 | 2021-06-04 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-04-19 | 2021-06-04 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-04-19 | 2021-06-04 | Y |
| 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. | Health | 2021-04-19 | 2021-06-04 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-04-19 | 2021-06-04 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-04-19 | 2021-06-04 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-04-19 | 2021-06-04 | Y |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2021-04-19 | 2021-06-04 | Y |
| Dispose of garbage and refuse properly. | Health | 2021-04-19 | 2021-06-04 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2021-04-19 | 2021-06-04 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-05-04 | Not Fixed | N |
