Deficiency Records for Liberty Commons Nrsg and Rehab Cntr of Southport LLC
Updated as of March 01, 2024
A list of the most recent deficiencies for Liberty Commons Nrsg and Rehab Cntr of Southport LLC. 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? |
|---|---|---|---|---|
| Use approved construction type or materials. | Fire Safety | 2022-12-22 | 2023-02-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-12-22 | 2023-02-04 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-11-21 | 2023-01-05 | N |
| 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 | 2022-11-21 | 2023-01-05 | 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 | 2022-11-21 | 2023-01-05 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-11-21 | 2023-01-05 | 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 | 2022-11-21 | 2023-01-05 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2022-11-21 | 2023-01-05 | 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 | 2022-11-21 | 2023-01-05 | 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 | 2022-11-21 | 2023-01-05 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-11-21 | 2023-01-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-11-21 | 2023-01-05 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2022-11-21 | 2023-01-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-11-21 | 2023-01-05 | N |
| Keep all essential equipment working safely. | Health | 2022-11-21 | 2023-01-05 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-11-21 | 2023-01-05 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-11-21 | 2023-01-05 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-11-21 | 2022-12-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-11-21 | 2022-12-22 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-11-21 | 2022-12-22 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-07-30 | 2021-08-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-30 | 2021-08-23 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-07-30 | 2021-08-23 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-07-30 | 2021-08-23 | Y |
| 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 | 2021-07-30 | 2021-08-19 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-07-30 | 2021-08-19 | Y |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2020-01-29 | 2020-02-26 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2020-01-29 | 2020-02-26 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-01-29 | 2020-02-26 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-01-09 | 2020-02-06 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2020-01-09 | 2020-02-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-01-09 | 2020-02-06 | N |
