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Deficiency Records for Liberty Retirement Community of Lima Inc
A list of the most recent deficiencies for Liberty Retirement Community of Lima Inc. 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 Retirement Community of Lima Inc. 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? |
|---|---|---|---|---|
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-07-22 | 2024-08-01 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-07-22 | 2024-08-01 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-05-08 | 2024-06-10 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-05-08 | 2024-06-10 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2024-05-08 | 2024-06-10 | 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 | 2024-05-08 | 2024-06-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-05-08 | 2024-06-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-05-08 | 2024-06-10 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-05-08 | 2024-06-10 | N |
| Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided. | Health | 2024-05-08 | 2024-06-10 | 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 | 2024-05-08 | 2024-06-10 | 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 | 2024-05-08 | 2024-06-10 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2024-05-08 | 2024-06-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-05-08 | 2024-06-10 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2024-05-08 | 2024-06-10 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-05-08 | 2024-06-10 | Y |
| Have enough outside ventilation via a window or mechanical ventilation, or both. | Health | 2024-05-08 | 2024-06-10 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2024-05-08 | 2024-06-10 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2024-05-08 | 2024-06-10 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-05-08 | 2024-06-10 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-05-08 | 2024-06-10 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-05-08 | 2024-06-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-05-08 | 2024-06-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-05-08 | 2024-06-10 | N |
| Install properly constructed windows in hallway walls or doors. | Fire Safety | 2024-05-08 | 2024-06-10 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-05-08 | 2024-06-10 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-05-08 | 2024-06-10 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-05-08 | 2024-06-10 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2024-05-08 | 2024-06-10 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2024-05-08 | 2024-06-10 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-05-08 | 2024-06-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-05-08 | 2024-06-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-12-29 | 2024-01-16 | 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 | 2023-07-06 | 2023-07-17 | Y |
| 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 | 2023-04-20 | 2023-06-01 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-04-20 | 2023-06-01 | Y |
| Provide appropriate foot care. | Health | 2023-04-20 | 2023-06-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-20 | 2023-06-01 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-04-20 | 2023-06-01 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2023-04-20 | 2023-06-01 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-04-20 | 2023-06-01 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-04-20 | 2023-06-01 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2023-04-20 | 2023-06-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-20 | 2023-06-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-03-02 | 2023-03-06 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-11-03 | 2021-12-13 | Y |
| 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 | 2021-11-03 | 2021-12-13 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-03 | 2021-12-13 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-03 | 2021-12-13 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-11-03 | 2021-12-13 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2021-11-03 | 2021-12-13 | 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 | 2021-11-03 | 2021-12-13 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-03 | 2021-12-13 | Y |
| Keep all essential equipment working safely. | Health | 2021-11-03 | 2021-12-13 | Y |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2021-11-03 | 2021-12-13 | Y |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2019-10-31 | 2019-12-02 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-10-31 | 2019-12-02 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-10-31 | 2019-12-02 | 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 | 2019-10-31 | 2019-12-02 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-10-31 | 2019-12-02 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-10-31 | 2019-12-02 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-10-31 | 2019-12-02 | N |
| Have an agreement with an approved laboratory to obtain services, if on-site laboratory services aren't provided. | Health | 2019-10-31 | 2019-12-02 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2019-10-31 | 2019-12-02 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-10-31 | 2019-12-02 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-10-31 | 2019-12-02 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-10-31 | 2019-12-02 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-10-28 | 2019-12-02 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-10-28 | 2019-12-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-10-28 | 2019-12-02 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-10-28 | 2019-12-02 | N |
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