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🔎 Liberty Commons Nandr Ctr Of Columbus Cty

Inspection Results


Inspection Overview

Liberty Commons Nandr Ctr Of Columbus Cty has been cited for a total of 38 deficiencies since we began saving each survey.

In North Carolina, the average facility has **29.80 deficiencies** in our database. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: F

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.

Survey Date: 2024-07-26
Correction Date: 2024-08-18
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: E

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Survey Date: 2024-07-26
Correction Date: 2024-08-18
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Survey Date: 2024-07-26
Correction Date: 2024-08-18
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2024-07-26
Correction Date: 2024-08-18
Category: Infection Control Deficiencies
From Complaint: N

Scope/Severity: K

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Survey Date: 2024-07-26
Correction Date: 2024-07-27
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: K

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2024-07-26
Correction Date: 2024-07-27
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2024-02-29
Correction Date: 2024-03-04
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: G

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Survey Date: 2024-02-29
Correction Date: 2024-02-29
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: G

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2024-02-29
Correction Date: 2024-02-29
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Survey Date: 2024-02-29
Correction Date: 2024-02-19
Category: Administration Deficiencies
From Complaint: Y

Scope/Severity: G

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Survey Date: 2024-02-29
Correction Date: 2024-03-20
Category: Administration Deficiencies
From Complaint: Y

Scope/Severity: G

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2023-09-15
Correction Date: 2023-09-12
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: G

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Survey Date: 2023-09-15
Correction Date: 2023-09-27
Category: Administration Deficiencies
From Complaint: Y

Scope/Severity: E

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

Survey Date: 2023-05-04
Correction Date: 2023-05-24
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Assure that each resident’s assessment is updated at least once every 3 months.

Survey Date: 2023-05-04
Correction Date: 2023-05-24
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: C

Post nurse staffing information every day.

Survey Date: 2023-05-04
Correction Date: 2023-05-24
Category: Nursing and Physician Services Deficiencies
From Complaint: N

Scope/Severity: E

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.

Survey Date: 2023-05-04
Correction Date: 2023-05-24
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2023-05-04
Correction Date: 2023-05-24
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Survey Date: 2023-05-04
Correction Date: 2023-05-24
Category: Administration Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident receives an accurate assessment.

Survey Date: 2023-05-04
Correction Date: 2023-05-24
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2023-05-04
Correction Date: 2023-05-24
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: G

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2023-05-04
Correction Date: 2023-05-24
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2022-08-11
Correction Date: 2022-08-24
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: D

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2022-04-05
Correction Date: 2022-04-14
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

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.

Survey Date: 2022-04-05
Correction Date: 2022-04-14
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2022-04-05
Correction Date: 2022-04-14
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident receives an accurate assessment.

Survey Date: 2022-04-05
Correction Date: 2022-04-14
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Survey Date: 2022-04-05
Correction Date: 2022-04-14
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: J

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Survey Date: 2022-04-05
Correction Date: 2022-04-14
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: K

Ensure that residents are free from significant medication errors.

Survey Date: 2022-04-05
Correction Date: 2022-04-14
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure each resident receives an accurate assessment.

Survey Date: 2020-12-10
Correction Date: 2020-12-25
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Have policies on smoking.

Survey Date: 2020-12-10
Correction Date: 2020-12-25
Category: Environmental Deficiencies
From Complaint: Y

Scope/Severity: D

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.

Survey Date: 2018-07-13
Correction Date: 2018-08-10
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident receives an accurate assessment.

Survey Date: 2018-07-13
Correction Date: 2018-08-10
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Ensure services provided by the nursing facility meet professional standards of quality.

Survey Date: 2018-07-13
Correction Date: 2018-08-10
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Survey Date: 2018-07-13
Correction Date: 2018-08-10
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: F

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2018-07-13
Correction Date: 2018-08-10
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: F

Have a plan that describes the process for conducting QAPI and QAA activities.

Survey Date: 2018-07-13
Correction Date: 2018-08-10
Category: Administration Deficiencies
From Complaint: N


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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**