Inspection Reports for
Liberty Care and Rehabilitation Center
616 S WALLACE WILKINSON BLVD, LIBERTY, KY, 42539
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
5.5 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
17% worse than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Routine
Deficiencies: 2
Date: Jul 9, 2025
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with medication self-administration policies and food service sanitation standards.
Findings
The facility failed to ensure proper assessment and physician orders for residents self-administering medications, specifically Resident #34. Additionally, the facility failed to maintain cleanliness of one nourishment room refrigerator and the ice machine, posing sanitation concerns.
Deficiencies (2)
F 0554: The facility failed to ensure Resident #34 was assessed and had a physician's order for self-administration of medication despite having an inhaler on the bedside table.
F 0812: The facility failed to maintain one nourishment room refrigerator and the ice machine in a clean and sanitary manner, with visible dried substances and stains.
Report Facts
Nourishment room refrigerators: 2
Residents reviewed for unnecessary medications: 5
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding medication self-administration procedures and Resident #34. |
| Director of Nursing | Director of Nursing | Interviewed about medication self-administration policy and refrigerator/ice machine cleaning expectations. |
| Administrator | Administrator | Interviewed about expectations for medication self-administration and sanitation of refrigerators and ice machines. |
| Dietary Manager | Dietary Manager | Interviewed about nourishment room refrigerator cleaning responsibilities. |
| District Dietary Manager | District Dietary Manager | Interviewed about ice machine cleanliness and dietary department responsibilities. |
| Staff Development Coordinator | Staff Development Coordinator | Interviewed about refrigerator cleaning responsibilities. |
| Plant Operations Director | Plant Operations Director | Observed and commented on ice machine cleanliness. |
| Registered Dietitian | Registered Dietitian | Interviewed about monthly sanitation reviews. |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Jun 14, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care, safety, and facility operations.
Findings
The facility failed to revise comprehensive care plans for residents with known risk behaviors, resulting in actual harm to residents. Specifically, a resident sustained a severe finger injury due to inadequate safety interventions during wheelchair transport, and another resident sustained a fall with no subsequent care plan updates. Additionally, the facility failed to provide adequate assistance with activities of daily living for some residents, and did not implement sufficient supervision and safety measures to prevent accidents.
Deficiencies (3)
F0657: The facility failed to revise comprehensive care plans for three residents with known risk behaviors, resulting in actual harm including a fracture and lacerations from wheelchair injury and a fall causing a skin tear.
F0677: The facility failed to provide adequate assistance with activities of daily living, including grooming and oral hygiene, for two residents who were unable to perform these tasks independently.
F0689: The facility failed to ensure adequate supervision and safety measures to prevent accidents, resulting in actual harm to two residents including a severe finger injury from wheelchair transport and a fall with skin tear.
Report Facts
Residents sampled: 42
Residents with care plan deficiencies: 3
Residents with ADL assistance deficiencies: 2
Residents with accident supervision deficiencies: 2
BIMS scores: 2
Laceration size: 2
Laceration size: 1.5
Pain rating: 7
Number of bed baths received: 8
Number of partial bed baths received: 2
Number of complete bed baths received: 5
Number of partial bed baths received: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| SRNA10 | State Registered Nurse Aide | Involved in transporting resident R37 when injury occurred; provided statements and interviews |
| SRNA4 | State Registered Nurse Aide | Witnessed injury to resident R37 during transport; provided statements and interviews |
| LPN5 | Licensed Practical Nurse | Assessed injury to resident R37, provided care and notified physician and family; involved in investigation |
| LPN6 | Licensed Practical Nurse | Found resident R29 after fall and provided care; notified physician and family |
| LPN3 | Unit Manager | Provided interviews regarding resident behaviors and care plan revisions |
| MDS Nurse | Nurse responsible for care plan revisions | Provided interviews about care plan updates and awareness of resident behaviors |
| DON | Director of Nursing | Provided interviews about staff training, care plan expectations, and incident response |
| Administrator | Facility Administrator | Provided interviews about facility expectations for care plan updates and resident safety |
| RSM | Rehabilitation Services Manager | Provided interviews about wheelchair use and resident mobility |
| OT | Occupational Therapist | Provided interviews about wheelchair recommendations and staff training |
| CNC | Corporate Nurse Consultant | Provided interview about incident notification and expectations for resident safety |
| Medical Director | Medical Director | Provided interview about incident and expectations for resident safety |
Inspection Report
Routine
Deficiencies: 10
Date: Jun 14, 2024
Visit Reason
Routine inspection of Liberty Care and Rehabilitation Center to assess compliance with healthcare regulations and resident care standards.
Findings
The facility had multiple deficiencies including failure to maintain a clean and homelike environment, incomplete PASARR Level II referrals, failure to revise comprehensive care plans after incidents, inadequate assistance with activities of daily living, medication errors including delayed and incorrect rifampin administration, improper medication storage and labeling, infection prevention and control lapses including failure to clean shared equipment and improper use of PPE, and failure to implement a comprehensive water management program.
Deficiencies (10)
F0584: Facility failed to maintain a clean and homelike environment; peeling paint, damaged doors, and urine odors were observed in multiple resident rooms and bathrooms.
F0645: Facility failed to make timely Level II PASARR referral for one resident despite positive Level I screening.
F0657: Facility failed to revise comprehensive care plans for three residents after incidents including injury from wheelchair spokes, falls, and wandering behaviors.
F0677: Facility failed to provide adequate assistance with activities of daily living for two residents, resulting in poor grooming, hygiene, and oral care.
F0689: Facility failed to ensure adequate supervision and assistive devices to prevent accidents for two residents, including injury from wheelchair spokes and a fall with no new interventions.
F0695: Facility failed to ensure oxygen tubing was dated as required by policy for one resident receiving oxygen therapy.
F0755: Facility failed to have prescribed rifampin medication available for one resident for four days after order date.
F0760: Facility failed to ensure residents were free from significant medication errors; one resident received half the prescribed rifampin dose for two days.
F0761: Facility failed to ensure medications and biologicals were labeled, dated, and stored according to accepted professional principles; two opened insulin vials lacked opened dates.
F0880: Facility failed to implement an effective infection prevention and control program including inadequate water management plan, improper cleaning of glucometers and shared equipment, failure to don PPE and perform hand hygiene, and improper catheter care.
Report Facts
Days medication delayed: 4
Rifampin tablets missing: 4
Rifampin tablets ordered: 30
Rifampin tablets dose: 2
Rifampin tablets dose: 1
BIMS score: 2
BIMS score: 6
BIMS score: 13
BIMS score: 12
Number of bed baths: 8
Number of partial bed baths: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN5 | Licensed Practical Nurse | Named in injury incident involving resident R37's finger caught in wheelchair spokes |
| SRNA4 | State Registered Nurse Aide | Witnessed injury incident involving resident R37's finger caught in wheelchair spokes |
| SRNA10 | State Registered Nurse Aide | Involved in injury incident involving resident R37's finger caught in wheelchair spokes |
| RN1 | Registered Nurse | Observed medication pass and cleaning lapses; named in infection control findings |
| LPN3 | Licensed Practical Nurse / Unit Manager | Named in infection control and care plan findings |
| SRNA6 | State Registered Nurse Aide | Failed to don PPE and perform hand hygiene before entering contact precaution room |
Inspection Report
Enforcement
Deficiencies: 6
Date: Dec 15, 2023
Visit Reason
The inspection was conducted due to allegations of resident abuse, including resident-to-resident abuse, failure to develop and implement comprehensive care plans, failure to notify appropriate authorities of abuse allegations, and failure to administer the facility effectively to prevent abuse.
Findings
The facility failed to protect residents from abuse, including sexual and physical abuse, failed to develop and implement adequate care plans addressing residents' behavioral needs, failed to notify state agencies and law enforcement of abuse allegations timely, and failed to provide adequate supervision and monitoring. Immediate Jeopardy was identified and later removed after the facility implemented corrective actions including education, care plan revisions, and monitoring.
Deficiencies (6)
Resident #2 was observed in Resident #1's bed with hand in Resident #1's genital area. Care plans and monitoring were inadequate to prevent this abuse.
Resident #2 was observed sitting on Resident #6's bed with hands under a blanket covering Resident #6's lap. Care plans and supervision failed to prevent this incident.
Resident #6 hit Resident #7 in the chest area. Care plans and interventions were not implemented to prevent or manage this behavior.
The facility failed to notify appropriate State Agencies and law enforcement of abuse allegations within required timeframes.
The facility failed to develop and implement comprehensive person-centered care plans addressing residents' medical, nursing, mental, and psychosocial needs related to abuse prevention.
The facility failed to administer the facility effectively to use resources to prevent abuse and ensure resident safety.
Report Facts
Residents with BIMS score 7 or less: 43
Residents with BIMS score 8 or higher: 39
Facility census: 83
Residents requiring care plan revision: 3
Residents needing care plans for sexual behaviors: 6
Inspection Report
Annual Inspection
Deficiencies: 1
Date: May 2, 2019
Visit Reason
The inspection was conducted as part of an annual survey to assess compliance with care plan implementation and resident dignity requirements.
Findings
The facility failed to implement comprehensive care plans for two residents requiring urinary catheter privacy covers. Observations confirmed the absence of dignity covers on urinary catheter drainage bags as specified in the care plans.
Deficiencies (1)
F 0656: The facility failed to implement the comprehensive care plan for two residents requiring urinary catheter privacy covers. Observations revealed urinary catheter drainage bags without dignity covers as care planned.
Report Facts
Residents sampled: 20
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding care plan implementation and staff expectations |
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