Inspection Reports for
West Liberty Nursing and Rehabilitation
774 LIBERTY ROAD, WEST LIBERTY, KY, 41472
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
6% worse than Kentucky average
Kentucky average: 4.7 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Aug 26, 2025
Visit Reason
The inspection was conducted as a comprehensive annual survey to assess compliance with regulatory requirements for nursing home operations, including staffing, medication management, food services, infection control, and environmental safety.
Findings
The facility was found deficient in multiple areas including failure to post daily nurse staffing data, improper medication storage with loose pills in medication carts, failure to follow menus and recipes resulting in poor food quality and resident dissatisfaction, inadequate accommodation of resident food preferences, lapses in infection prevention and control practices, and environmental safety issues such as cracked and missing tiles causing an unsafe and unclean environment.
Deficiencies (7)
F 0732: The facility failed to post daily nurse staffing information at the beginning of each shift for three days, and staff were not trained on posting procedures.
F 0761: The facility failed to ensure proper medication storage; loose pills were found in medication cart drawers, risking medication errors.
F 0803: The facility failed to follow the menu as written; substitutions and omissions led to meals lacking required ingredients and seasoning.
F 0804: The facility failed to ensure food and drinks were palatable, attractive, and served at safe temperatures; residents reported poor taste and texture.
F 0806: The facility failed to accommodate resident food preferences and dislikes for 3 sampled residents, resulting in dissatisfaction and unmet dietary needs.
F 0880: The facility failed to implement an effective infection prevention and control program; issues included improper hand hygiene, unsafe handling of body fluids, incomplete temperature logs, and unsafe environmental practices.
F 0921: The facility failed to maintain a safe, clean, and homelike environment; multiple areas had cracked or missing tiles, holes in walls, and peeling baseboards causing resident discomfort and safety risks.
Report Facts
Loose pills found: 36
Temperature log missing entries: 6
Cracked tiles: 18
Missing tiles: 10
Residents affected: 3
Residents affected: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse 1 | Registered Nurse | Interviewed regarding nurse staffing posting |
| Director of Nursing | Director of Nursing | Responsible for posting daily staffing coverage and infection control oversight |
| Administrator | Administrator | Provided statements on staffing posting and infection control expectations |
| Kentucky Medication Aid 1 | Medication Aid | Interviewed about medication cart loose pills |
| Registered Nurse 2 | Registered Nurse | Interviewed about medication cart and infection control practices |
| Dietary Manager | Dietary Manager | Interviewed about menu preparation, food palatability, and food preference forms |
| Regional Dietary Manager | Regional Dietary Manager | Interviewed about menu adherence and food preparation |
| State Registered Nursing Assistant 5 | State Registered Nursing Assistant | Interviewed about resident food preferences |
| Housekeeping Supervisor | Housekeeping Supervisor | Interviewed about cleaning practices and environmental maintenance |
| Certified Nursing Assistant 1 | Certified Nursing Assistant | Observed and interviewed regarding infection control lapses |
| Infection Preventionist | Infection Preventionist | Interviewed about infection control program deficiencies |
| Senior Maintenance Director | Senior Maintenance Director | Interviewed about environmental maintenance and repair prioritization |
Inspection Report
Deficiencies: 1
Date: Aug 26, 2025
Visit Reason
The inspection was conducted to assess compliance with food quality and palatability standards in the nursing home.
Findings
The facility failed to ensure that food and drinks were palatable, attractive, and served at a safe and appetizing temperature during one meal tray tested. The dietary staff did not follow the recipe, resulting in bland food lacking seasoning and improper preparation.
Deficiencies (1)
F 0804: The facility failed to ensure food and drink were palatable, attractive, and served at a safe and appetizing temperature. The dietary staff did not follow the recipe, seasoning was eyeballed, and the meal was bland and lacked proper ingredients.
Report Facts
Food temperature: 125.4
Food temperature: 126.1
Food temperature: 46.2
Food temperature: 52.5
Food temperature: 50.9
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Jan 25, 2023
Visit Reason
The inspection was conducted due to complaints and concerns regarding the facility's failure to notify residents and representatives of transfers, failure to provide written bed-hold policy information, inadequate care planning and supervision for residents at risk of elopement, and infection control issues.
Complaint Details
The investigation was complaint-driven, triggered by reports of failure to notify of transfers, inadequate care planning and supervision for elopement risk, and infection control breaches. The complaint included an anonymous report of a resident eloping and concerns about notification and care practices.
Findings
The facility failed to notify residents and representatives in writing of transfers to hospitals, failed to provide written bed-hold policy information, failed to develop and implement adequate care plans for residents at risk of elopement, and failed to provide adequate supervision to prevent elopements. Additionally, the facility failed to ensure proper infection control practices during wound care, including changing contaminated gloves and preventing contamination of wound care supplies.
Deficiencies (5)
F0623: The facility failed to notify the resident and representative in writing of a hospital transfer and failed to notify the Long-Term Care Ombudsman for one resident.
F0625: The facility failed to provide written information regarding the bed-hold policy to a resident and representative when the resident was transferred to the hospital.
F0656: The facility failed to develop and implement a comprehensive care plan with necessary interventions for monitoring a resident at risk for elopement, resulting in an elopement incident.
F0689: The facility failed to provide adequate supervision and monitoring to prevent elopement for one resident, who eloped and was found 1.6 miles away without staff knowledge.
F0880: The facility failed to ensure staff changed contaminated gloves during incontinent and wound care and failed to prevent contamination of wound care supplies for one resident.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 2
Staff trained: 29
Staff trained: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #5 | Licensed Practical Nurse | Interviewed regarding notification of transfers and elopement incident |
| LPN #9 | Licensed Practical Nurse | Interviewed regarding notification of transfers |
| Director of Nursing Services | DNS | Interviewed regarding notification, elopement investigation, and care planning |
| Executive Director | ED | Interviewed regarding notification, elopement incident, and care planning |
| Maintenance #1 | Maintenance Staff | Interviewed regarding window audit and door alarms |
| ADNS | Assistant Director of Nursing Services | Observed providing wound care with infection control breaches |
| SRNA #13 | State Registered Nurse Aide | Interviewed regarding elopement incident and window condition |
| Medical Records Nurse | Medical Records Nurse | Interviewed regarding elopement incident and assessments |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jan 30, 2020
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to implement a comprehensive care plan and maintain a safe environment for a resident at high risk for falls.
Complaint Details
The complaint investigation found that Resident #6, who had severe cognitive impairment and was at high risk for falls, fell on 01/17/2020 after tripping over a fan cord stretched across the room. The resident suffered no injury. The facility failed to maintain clear pathways and address the hazard despite having a care plan and interventions in place.
Findings
The facility failed to implement the care plan for Resident #6, who was at high risk for falls, resulting in a fall caused by tripping over a fan cord stretched across the room. The environment was not free from accident hazards as the fan cord was suspended across the room in front of the resident's recliner, posing a safety risk.
Deficiencies (2)
F 0656: The facility failed to implement a complete care plan for Resident #6, who was at high risk for falls, as pathways in the resident's room were not kept clear, leading to a fall caused by tripping over a fan cord.
F 0689: The facility failed to ensure the resident environment was free from accident hazards, as the fan cord was stretched across the room in front of the recliner, posing a fall hazard for Resident #6.
Report Facts
Residents sampled: 13
Residents affected: 1
BIMS score: 6
Fall date: Jan 17, 2020
Observation dates: Jan 29, 2020
Observation dates: Jan 30, 2020
Cord height: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding the hazard and care plan implementation failures | |
| Maintenance staff | Interviewed about awareness of the fan cord hazard |
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