Federal Nursing-Home Survey Record
Liberty Commons Nursing & Rehab Center of Southpor
Does Liberty Commons Nursing & Rehab Center of Southpor have a federal violation or abuse history?
According to the public federal record on file with the Centers for Medicare & Medicaid Services (CMS), Liberty Commons Nursing & Rehab Center of Southpor (CCN 345373), in Southport, NC, has federal inspection findings on its record.
In its current inspection cycle, CMS cited the facility for 6 deficiencies; the most serious carries scope/severity D on CMS's A–L scale — CMS's "potential for harm" tier, below actual harm. Citations from earlier inspection cycles appear in the dated timeline below as historical findings, not current ones. This page restates the federal record as published by CMS and draws no conclusion of its own. Federal nursing-home surveys are conducted on a recurring cycle by state survey agencies acting on CMS's behalf, and the figures on this page are compiled from CMS's published provider data, as on file with CMS; the federal record may understate what actually occurred, and inspection findings are point-in-time survey results, not a determination that any specific resident was harmed.
The Federal Record
The most recent federal inspection on file records no actual-harm or immediate-jeopardy citations for this facility.
Below is this facility's federal survey record as on file with CMS.
Scope & Severity — current cycle
Overall CMS star rating: this facility vs the CMS-published state average
This facility: 3 · CMS state average: 2.9
Deficiency timeline — full federal history
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Ensure services provided by the nursing facility meet professional standards of quality.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Provide and implement an infection prevention and control program.
Provide timely, quality laboratory services/tests to meet the needs of residents.
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.
25 citations from earlier inspection cycles — historical, not current (expand)
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Ensure that residents are free from significant medication errors.
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Assist a resident in gaining access to vision and hearing services.
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.
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Keep all essential equipment working safely.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
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.
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Provide and implement an infection prevention and control program.
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.
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.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Ensure each resident receives an accurate assessment.
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.
Provide enough food/fluids to maintain a resident's health.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Document what happened
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