Deficiency Records for Liberty Commons Nsg and Rehab Ctr of Johnston Cty
Updated as of March 01, 2024
A list of the most recent deficiencies for Liberty Commons Nsg and Rehab Ctr of Johnston Cty. 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? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-12-08 | 2023-12-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-12-08 | 2023-12-21 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-12-08 | 2023-12-21 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-12-08 | 2023-12-21 | Y |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2023-12-08 | 2023-12-21 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-12-08 | 2023-11-03 | 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 | 2023-05-25 | 2023-08-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-05-25 | 2023-08-15 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2023-05-25 | 2023-08-15 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-05-25 | 2023-08-15 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-05-25 | 2023-08-15 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-04-21 | 2023-06-06 | 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 | 2023-04-21 | 2023-06-06 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-04-21 | 2023-06-06 | N |
| 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. | Health | 2023-04-21 | 2023-06-06 | 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 | 2023-04-21 | 2023-06-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-21 | 2023-06-06 | N |
| Dispose of garbage and refuse properly. | Health | 2023-04-21 | 2023-06-06 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-04-21 | 2023-06-06 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2023-04-21 | 2023-06-06 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-04-21 | 2023-06-06 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-04-21 | 2023-06-06 | 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 | 2023-04-21 | 2023-06-06 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-04-21 | 2023-06-06 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-04-21 | 2023-06-06 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-02 | 2023-05-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-21 | 2023-04-21 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2022-10-27 | 2022-12-02 | 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 | 2022-10-27 | 2022-12-02 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-02-25 | 2022-05-01 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-02-25 | 2022-04-14 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-02-25 | 2022-04-14 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-02-25 | 2022-04-14 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-02-25 | 2022-04-14 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-02-25 | 2022-04-14 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-02-25 | 2022-04-14 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-02-25 | 2022-04-14 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-25 | 2022-04-14 | 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 | 2022-02-25 | 2022-04-14 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-02-25 | 2022-04-14 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-02-25 | 2022-04-14 | 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 | 2022-02-25 | 2022-04-14 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-02-25 | 2022-04-14 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-02-25 | 2022-04-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-25 | 2022-04-14 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-25 | 2022-04-14 | 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 | 2022-02-25 | 2022-04-14 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-02-25 | 2022-04-14 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-02-25 | 2022-04-14 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-02-25 | 2022-04-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-25 | 2022-04-14 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-02-25 | 2022-04-14 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-02-25 | 2022-03-30 | N |
| Post nurse staffing information every day. | Health | 2022-02-25 | 2022-03-30 | 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 | 2022-02-25 | 2022-03-30 | Y |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2019-10-03 | 2019-10-21 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-03 | 2019-10-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-10-03 | 2019-10-21 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-08-29 | 2019-09-26 | 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 | 2019-08-29 | 2019-09-26 | N |
| Provide activities to meet all resident's needs. | Health | 2019-08-29 | 2019-09-26 | 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 | 2019-08-29 | 2019-09-26 | N |
