Deficiency Records for Liberty Commons Nsg and Rehab Ctr of Lee County
Updated as of April 01, 2024
A list of the most recent deficiencies for Liberty Commons Nsg and Rehab Ctr of Lee County. 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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-06 | 2023-08-15 | Y |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-07-06 | 2023-08-15 | Y |
| Use approved construction type or materials. | Fire Safety | 2023-03-21 | 2023-04-07 | 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 | 2023-03-21 | 2023-04-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-21 | 2023-04-07 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-03-21 | 2023-04-07 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-03-21 | 2023-04-07 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-02-09 | 2023-03-17 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-02-09 | 2023-03-17 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-09 | 2023-03-17 | N |
| Respond appropriately to all alleged violations. | Health | 2023-02-09 | 2023-03-17 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-02-09 | 2023-03-17 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-02-09 | 2023-03-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-09 | 2023-03-17 | 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 | 2023-02-09 | 2023-03-17 | 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 | 2023-02-09 | 2023-03-17 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-02-09 | 2023-03-17 | 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 | 2023-02-09 | 2023-03-17 | 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 | 2023-02-09 | 2023-03-17 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-09 | 2023-03-17 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-02-09 | 2023-03-17 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-02-09 | 2023-03-17 | N |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2023-02-09 | 2023-03-17 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-09 | 2023-03-17 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-09 | 2023-03-17 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-09 | 2023-03-17 | 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 | 2023-02-09 | 2023-03-17 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-02-09 | 2023-03-17 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2023-02-09 | 2023-03-17 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-09 | 2022-08-18 | Y |
| Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy. | Fire Safety | 2022-03-17 | 2022-05-05 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-03-17 | 2022-05-05 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-02-17 | 2022-03-29 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2022-02-17 | 2022-03-29 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-02-17 | 2022-03-29 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-02-17 | 2022-03-29 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-02-17 | 2022-03-29 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-02-17 | 2022-03-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-02-17 | 2022-03-29 | N |
| Provide activities to meet all resident's needs. | Health | 2022-02-17 | 2022-03-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-17 | 2022-03-29 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-02-17 | 2022-03-29 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-02-17 | 2022-03-29 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-02-17 | 2022-03-29 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2022-02-17 | 2022-03-29 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-02-17 | 2022-03-29 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-02-17 | 2022-03-29 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-02-17 | 2022-03-29 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-02-17 | 2022-03-29 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-17 | 2022-03-29 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-02-17 | 2022-03-29 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-02-17 | 2022-03-29 | Y |
| Perform COVID19 testing on residents and staff. | Health | 2022-02-17 | 2022-03-29 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-02-17 | 2022-03-29 | Y |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2022-02-17 | 2022-03-18 | 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 | 2022-02-17 | 2022-03-09 | 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 | 2020-03-03 | 2020-04-03 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-03-03 | 2020-04-03 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-03-03 | 2020-04-03 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-02-06 | 2020-03-03 | 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 | 2020-02-06 | 2020-03-03 | N |
| 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 | 2020-02-06 | 2020-03-03 | N |
| Assess the resident when there is a significant change in condition | Health | 2020-02-06 | 2020-03-03 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2020-02-06 | 2020-03-03 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-02-06 | 2020-03-03 | 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 | 2020-02-06 | 2020-03-03 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2020-02-06 | 2020-03-03 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-02-06 | 2020-03-03 | N |
| Provide activities to meet all resident's needs. | Health | 2020-02-06 | 2020-03-03 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2020-02-06 | 2020-03-03 | 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 | 2020-02-06 | 2020-03-03 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-02-06 | 2020-03-03 | 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 | 2020-02-06 | 2020-03-03 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-02-06 | 2020-03-03 | 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 | 2020-02-06 | 2020-03-03 | N |
| Post nurse staffing information every day. | Health | 2020-02-06 | 2020-03-03 | 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 | 2020-02-06 | 2020-03-03 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2020-02-06 | 2020-03-03 | 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 | 2020-02-06 | 2020-03-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-02-06 | 2020-03-03 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2020-02-06 | 2020-03-03 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2020-02-06 | 2020-03-03 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2020-02-06 | 2020-03-03 | N |
