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Deficiency Records for Libertyville Manor Ext Care
A list of the most recent deficiencies for Libertyville Manor Ext Care. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Libertyville Manor Ext Care. 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? |
|---|---|---|---|---|
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2024-04-17 | 2024-06-03 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-08 | 2024-05-10 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2024-02-08 | 2024-05-10 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2024-02-28 | 2024-04-30 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2024-02-28 | 2024-04-30 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2024-02-28 | 2024-04-30 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2024-02-28 | 2024-04-30 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2024-02-28 | 2024-04-30 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2024-02-28 | 2024-04-30 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2024-02-28 | 2024-04-30 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-02-28 | 2024-04-30 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2024-02-28 | 2024-04-30 | N |
| Install proper backup exit lighting. | Fire Safety | 2024-02-28 | 2024-04-30 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-02-28 | 2024-04-30 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-02-28 | 2024-04-30 | 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 | 2024-02-28 | 2024-04-30 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2024-02-28 | 2024-04-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-02-28 | 2024-04-30 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-02-28 | 2024-04-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-02-28 | 2024-04-30 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2024-02-08 | 2024-04-11 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2024-02-08 | 2024-03-31 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2024-02-08 | 2024-03-31 | 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 | 2024-02-08 | 2024-03-31 | N |
| 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 | 2024-02-08 | 2024-03-31 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2024-02-28 | 2024-03-31 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2024-02-28 | 2024-03-21 | N |
| Implement emergency and standby power systems. | Fire Safety | 2024-02-28 | 2024-03-21 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2024-02-28 | 2024-03-21 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2024-02-28 | 2024-03-21 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-02-28 | 2024-02-28 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-04-14 | 2023-12-31 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-10-20 | 2023-11-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-20 | 2023-10-21 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-14 | 2023-08-14 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-04-14 | 2023-07-14 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2023-04-14 | 2023-05-29 | N |
| Implement emergency and standby power systems. | Fire Safety | 2023-04-14 | 2023-05-29 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-04-14 | 2023-05-29 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-04-14 | 2023-05-29 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-04-14 | 2023-05-29 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-14 | 2023-05-29 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-04-14 | 2023-05-29 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-04-14 | 2023-05-29 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-04-14 | 2023-05-29 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-04-14 | 2023-05-29 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-04-14 | 2023-05-29 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-04-14 | 2023-05-29 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-04-14 | 2023-05-29 | 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 | 2023-03-22 | 2023-04-28 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-22 | 2023-04-28 | 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 | 2023-03-22 | 2023-04-28 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2023-03-22 | 2023-04-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-03-22 | 2023-04-28 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-04-14 | 2023-04-14 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2023-04-14 | 2023-04-14 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-04-14 | 2023-04-14 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-04-14 | 2023-04-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-04-14 | 2023-04-14 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-04-14 | 2023-04-14 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-04-14 | 2023-04-14 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-04-14 | 2023-04-14 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-04-14 | 2023-04-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-04-14 | 2023-04-14 | 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 | 2023-01-19 | 2023-02-06 | Y |
| 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 | 2022-06-15 | 2022-11-23 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-06-29 | 2022-08-25 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-06-29 | 2022-08-24 | 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 | 2022-06-15 | 2022-08-04 | 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 | 2022-06-15 | 2022-07-31 | 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 | 2022-06-15 | 2022-07-31 | N |
| Perform COVID19 testing on residents and staff. | Health | 2022-06-15 | 2022-07-31 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-06-15 | 2022-07-22 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2022-06-29 | 2022-07-22 | N |
| Provide emergency officials' contact information. | Fire Safety | 2022-06-29 | 2022-07-13 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-06-29 | 2022-07-13 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-06-29 | 2022-07-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-29 | 2022-07-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-06-29 | 2022-07-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-06-29 | 2022-07-13 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-06-29 | 2022-07-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-29 | 2022-07-13 | 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 | 2022-05-31 | 2022-07-11 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-05-31 | 2022-07-11 | Y |
| Have exits that are accessible at all times. | Fire Safety | 2022-06-29 | 2022-07-11 | 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 | 2022-06-29 | 2022-07-05 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-06-29 | 2022-07-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-14 | 2021-11-30 | Y |
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