Deficiency Records for Liberty Commons Rehabilitation Center
Updated as of March 01, 2024
A list of the most recent deficiencies for Liberty Commons Rehabilitation Center. 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? |
|---|---|---|---|---|
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-11-02 | 2023-12-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-11-02 | 2023-12-15 | 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 | 2023-11-02 | 2023-12-15 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-11-02 | 2023-12-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-02 | 2023-12-15 | N |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-11-02 | 2023-12-15 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-11-02 | 2023-12-15 | 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 | 2023-11-02 | 2023-12-15 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-11-02 | 2023-12-15 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-11-28 | 2023-12-15 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2023-11-28 | 2023-12-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-11-28 | 2023-12-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-02 | 2023-11-02 | Y |
| Install noncombustible or limited-combustible interior walls. | Fire Safety | 2022-08-03 | 2022-09-12 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-08-03 | 2022-09-12 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-03 | 2022-09-12 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-08-03 | 2022-09-12 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-07-15 | 2022-08-12 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-07-15 | 2022-08-12 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-07-15 | 2022-08-11 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-07-15 | 2022-08-10 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-07-15 | 2022-08-05 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-07-15 | 2022-08-05 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2022-07-15 | 2022-08-04 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-07-15 | 2022-07-15 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2021-05-03 | 2021-05-28 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-05-03 | 2021-05-28 | 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 | 2021-05-03 | 2021-05-28 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-05-03 | 2021-05-28 | 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 | 2021-05-03 | 2021-05-28 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-05-03 | 2021-05-28 | N |
| Post nurse staffing information every day. | Health | 2021-05-03 | 2021-05-28 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-05-03 | 2021-05-28 | 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 | 2021-05-03 | 2021-05-28 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2021-05-03 | 2021-05-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-05-03 | 2021-05-28 | N |
| Keep all essential equipment working safely. | Health | 2021-05-03 | 2021-05-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-05-03 | 2021-05-28 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-05-03 | 2021-05-28 | Y |
