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Deficiency Records for Liberty Health and Wellness

A list of the most recent deficiencies for Liberty Health and Wellness. 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 Liberty Health and Wellness. 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 2024-04-23 2024-05-20 Y
Provide medically-related social services to help each resident achieve the highest possible quality of life. Health 2024-04-23 2024-05-20 Y
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Health 2024-04-23 2024-05-20 Y
Protect each resident from the wrongful use of the resident's belongings or money. Health 2024-04-23 2024-04-23 Y
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Health 2023-10-16 2023-11-30 N
Provide care or services that was trauma informed and/or culturally competent. Health 2023-10-16 2023-11-30 N
Post nurse staffing information every day. Health 2023-10-16 2023-11-30 N
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Health 2023-10-16 2023-11-30 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 2023-10-16 2023-11-30 N
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Health 2023-10-16 2023-11-30 N
Provide and implement an infection prevention and control program. Health 2023-10-16 2023-11-30 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 2023-10-16 2023-11-30 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2023-10-16 2023-11-30 Y
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2023-10-16 2023-11-30 N
Have simulated fire drills held at unexpected times. Fire Safety 2023-10-16 2023-11-30 N
Have generator or other power source capable of supplying service within 10 seconds. Fire Safety 2023-10-16 2023-11-30 N
Have proper medical gas storage and administration areas. Fire Safety 2023-10-16 2023-11-30 N
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Health 2023-05-04 2023-07-14 N
Reasonably accommodate the needs and preferences of each resident. Health 2023-05-04 2023-07-14 N
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Health 2023-05-04 2023-07-14 N
Honor the resident's right to organize and participate in resident/family groups in the facility. Health 2023-05-04 2023-07-14 N
Ensure residents have reasonable access to and privacy in their use of communication methods. Health 2023-05-04 2023-07-14 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 2023-05-04 2023-07-14 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 2023-05-04 2023-07-14 N
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. Health 2023-05-04 2023-07-14 N
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2023-05-04 2023-07-14 N
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Health 2023-05-04 2023-07-14 N
Provide activities to meet all resident's needs. Health 2023-05-04 2023-07-14 N
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2023-05-04 2023-07-14 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 2023-05-04 2023-07-14 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 2023-05-04 2023-07-14 N
Ensure medication error rates are not 5 percent or greater. Health 2023-05-04 2023-07-14 N
Ensure that residents are free from significant medication errors. Health 2023-05-04 2023-07-14 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 2023-05-04 2023-07-14 N
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration. Health 2023-05-04 2023-07-14 N
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2023-05-04 2023-07-14 N
Provide and implement an infection prevention and control program. Health 2023-05-04 2023-07-14 N
Implement a program that monitors antibiotic use. Health 2023-05-04 2023-07-14 N
Provide immediate access to any resident. Health 2023-05-04 2023-07-14 Y
Ensure services provided by the nursing facility meet professional standards of quality. Health 2023-05-04 2023-07-14 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2023-05-04 2023-07-14 Y
Provide appropriate treatment and care according to orders, resident?s preferences and goals. Health 2023-05-04 2023-07-14 Y
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Health 2023-05-04 2023-07-14 Y
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Health 2023-05-04 2023-07-14 Y
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Health 2023-05-04 2023-07-14 Y
Address subsistence needs for staff and patients. Fire Safety 2023-05-04 2023-07-14 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 2023-05-04 2023-07-14 N
Have approved installation, maintenance and testing program for fire alarm systems. Fire Safety 2023-05-04 2023-07-14 N
Install an approved automatic sprinkler system. Fire Safety 2023-05-04 2023-07-14 N
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Fire Safety 2023-05-04 2023-07-14 N
Provide a written emergency evacuation plan. Fire Safety 2023-05-04 2023-07-14 N
Ensure proper usage of power strips and extension cords. Fire Safety 2023-05-04 2023-07-14 N
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. Health 2022-09-02 2022-09-02 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-09-02 2022-09-02 Y
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Health 2022-09-02 2022-09-02 Y
Honor the resident's right to organize and participate in resident/family groups in the facility. Health 2022-07-12 2022-08-25 Y
The resident has the right to receive notices in a format and a language he or she understands. Health 2022-07-12 2022-08-25 Y
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Health 2022-07-12 2022-08-25 Y
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Health 2022-07-12 2022-08-25 Y
Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. Health 2022-07-12 2022-08-25 Y
Ensure services provided by the nursing facility meet professional standards of quality. Health 2022-07-12 2022-08-25 Y
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. Health 2022-07-12 2022-08-25 Y
Provide care and assistance to perform activities of daily living for any resident who is unable. Health 2022-07-12 2022-08-25 Y
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. Health 2022-07-12 2022-08-25 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2022-07-12 2022-08-25 Y
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Health 2022-07-12 2022-08-25 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 2022-07-12 2022-08-25 Y
Provide safe and appropriate respiratory care for a resident when needed. Health 2022-07-12 2022-08-25 Y
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. Health 2022-07-12 2022-08-25 Y
Ensure medication error rates are not 5 percent or greater. Health 2022-07-12 2022-08-25 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 2022-07-12 2022-08-25 Y
Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Health 2022-07-12 2022-08-25 Y
Provide special eating equipment and utensils for residents who need them and appropriate assistance. Health 2022-07-12 2022-08-25 Y
Make sure that a working call system is available in each resident's bathroom and bathing area. Health 2022-07-12 2022-08-25 Y
Ensure staff are vaccinated for COVID-19 Health 2022-02-24 2022-03-15 Y
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. Health 2022-01-19 2022-03-15 Y
Develop and implement policies and procedures to prevent abuse, neglect, and theft. Health 2022-01-19 2022-03-15 Y
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Health 2022-01-19 2022-03-15 Y
Respond appropriately to all alleged violations. Health 2022-01-19 2022-03-15 Y
Ensure services provided by the nursing facility meet professional standards of quality. Health 2022-01-19 2022-03-15 Y
Plan the resident's discharge to meet the resident's goals and needs. Health 2022-01-19 2022-03-15 Y
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Health 2022-01-19 2022-03-15 Y
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. Health 2022-01-19 2022-03-15 Y
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Health 2022-01-19 2022-03-15 Y
Provide and implement an infection prevention and control program. Health 2022-01-19 2022-03-15 Y
Implement a program that monitors antibiotic use. Health 2022-01-19 2022-03-15 Y
Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Health 2022-01-19 2022-03-15 Y
Develop and implement policies and procedures for flu and pneumonia vaccinations. Health 2022-01-19 2022-03-15 Y
Report COVID19 data to residents and families. Health 2022-01-19 2022-03-15 Y
Perform COVID19 testing on residents and staff. Health 2022-01-19 2022-03-15 Y
Ensure services provided by the nursing facility meet professional standards of quality. Health 2021-11-22 2022-03-15 Y
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Health 2021-11-22 2021-11-22 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 2021-11-22 2021-11-22 Y
Inspect, test, and maintain automatic sprinkler systems. Fire Safety 2023-05-04 Not Fixed N

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