LIBERTY, KY- LIBERTY CARE AND REHABILITATION CENTER

The Department of Health & Human Services conducted an inspection of the facility. The following  highlighted decencies listed below were found in a public survey, that can be found by clicking on “Full State Report” at the bottom.

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

Based on observation, interview, record review, and review of the facility’s policy, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for two (2) of eight (8) sampled residents reviewed for accidents out of a total sample of 42 residents, Resident (R), R29 and R37.

On 06/09/2024, during transfer back to R37’s room, staff allowed the resident’s left hand to become entangled in the Evolution Mobility (brand of wheelchair) wheelchair’s wheel spokes. The resident was transferred to the local Hospital Emergency Department and was noted to have two (2) lacerations on the left second finger. One (1) laceration, measured 2.0 centimeters (cm), with exposed bone in the proximal region of the finger, while the other, measured 1.5 cm, and was located at the medial joint. R37 was subsequently transferred to the University Hospital Emergency Department to seek evaluation by a hand specialist where the resident was diagnosed with an open fracture to her left index finger, with an approximate 2.0 cm laceration to the metacarpophalangeal joint.

Additionally, R29 sustained a fall on 06/10/2024, while searching for something in his closet, and was found on his knees beside the closet door. The resident sustained a skin tear to the right forearm (RFA). However, there was no documented evidence the facility initiated new interventions to prevent recurrence.

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.

Based on observation, interview, and review of the facility’s documents and policies, the facility failed to provide a clean and homelike environment for residents.

Observations on 06/10/2024 and 06/11/2024, revealed the facility failed to ensure the interior of the building including residents’ room walls and residents’ room doors were in good repair. The observations revealed peeling paint or missing paint on the walls and some areas had wood missing from the doors leaving rough edges or gouges. Additionally, residents’ rooms and bathrooms had a strong odor of urine. This affected the rooms and/or bathrooms for rooms 216, 217, 218, 219, 220, 221, 222, 223, 224, 225, and 226.

Additionally, the shared bathroom between rooms [ROOM NUMBERS] had two (2) open urinals containing urine, hung on the handrail which were not bagged. One (1) of the urinals was not labeled for identification.

PASARR screening for Mental disorders or Intellectual Disabilities

Based on interview, record review, and review of the facility’s policy, the facility failed to make the
appropriate Level II Preadmission Screening and Resident Review (PASARR) referral based on the positive Level 1 PASARR screening results for one (1) of two (2) sampled residents reviewed for PASARR Screening (Resident (R)19) out of a total sample of forty-two residents.

The facility assessed R19 to have a positive Level I PASARR screen at admission on 06/15/2023. This
screening indicated the resident required a Level II Screening; however, the facility failed to ensure a Level II Screening was completed in the required timeframe.

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Based on interview, record review, and review of the facility’s policies, the facility failed to review and revise the comprehensive care plan (CCP) for three (3) of 42 sampled residents, (Residents (R), R29, R37, and R49).

Although staff was aware R37 had a history of grabbing onto the wheelchair wheels of her Evolution Mobility wheelchair when she did not want to be transported by staff, the facility did not revise her Comprehensive Care Plan (CCP) with safety interventions to prevent injury related to this behavior. On 06/09/2024, R37 was  being transported by staff to her room when her hand was caught in the wheel spokes of her wheelchair, causing her to sustain a fracture and lacerations to her left index finger.

Additionally, R29 sustained a fall on 06/10/2024 when searching for something in his closet, causing a skin tear to his right forearm (RFA). However, there was no documented evidence the resident’s CCP was revised to prevent recurrence.

Furthermore, R49’s CCP, dated 12/07/2023, revised 04/17/2024, revealed the resident exhibited behaviors of entering other residents’ rooms and had removed personal belongings from those rooms. Also, the Progress Note, dated 05/28/2024, revealed the resident was trying to enter the room of another resident. Observation on 06/11/2024 revealed the resident was trying to enter R4’s room and on 06/12/2024 the resident was trying to enter the locked soiled utility room. Although resident interviews revealed the resident continued to enter their rooms, and staff interviews revealed they were aware of the resident’s behaviors of attempting to enter other residents’ rooms; there was no documented evidence the resident’s CCP was revised, in an attempt to prevent recurrence.

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

Based on observation, interview, record review, and review of facility policy, it was determined the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming, and personal and oral hygiene for two (2) of 42 sampled residents, Resident #55 and #55 (R55 and R58).

R55 complained on 06/12/2024, staff had not brushed her teeth or swabbed her mouth, and she did not receive assistance with mouth care very often. R55 further complained she was given a bed bath twice a week and her privates were washed only when she had a bowel movement.

Additionally, observation of R58, on 06/10/2024 and 06/11/2024, revealed his fingernails were long and dirty and he had not been shaved. R58 was wearing the same dark gray shirt both days.

Provide safe and appropriate respiratory care for a resident when needed.

Based on observation, interview, and review of the facility’s policy, the facility failed to ensure residents requiring respiratory care received care consistent with professional standards of practice for one (1) resident reviewed for respiratory care out of a total of 42 sampled residents, Resident #58 (R58).

Observation on 06/10/2024 and 06/11/2024, revealed R58 was receiving oxygen at two (2) liters per minute per nasal cannula as per Physician’s Orders. However, the oxygen tubing was not dated.

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Based on interview, record review, and review of facility policy, the facility failed to have prescribed
medications available to administer for one (1) of 42 sampled residents, Resident #332 (R322).

R322’s Physician’s Orders, dated 06/07/2024, untimed, revealed orders for rifampin 300 milligrams (mg), two (2) tablets, to be administered daily between 7:00 AM and 11:00 AM. However, the medication was not delivered to the facility until 06/10/2024 at 8:15 PM, four (4) days after it was ordered.

Ensure that residents are free from significant medication errors.

Based on observation, interview, record review, and review of the facility’s policy, the facility failed to ensure residents were free of significant medication errors for one (1) of 42 sampled residents, Resident 332 (R322).

On 06/07/2024, R322 was prescribed two (2), 300 milligram (mg) tablets of rifampin (antibiotic to treat Tuberculosis) to be given once daily. However, R322 received half the dose (1 table, 300 mg) on 06/11/2024, and 06/12/2024.

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.

Based on observation, interview, and review of the facility’s policy, the facility failed to ensure drugs and biological’s used in the facility were labeled, dated, and stored in accordance with currently accepted professional principles for one (1) of four (4) medication carts.

Observation of the North Wing’s A-C Medication Cart, on [DATE] at 10:15 AM, revealed two (2) opened vials of Insulin Glargine U100 with no opened date.

Provide and implement an infection prevention and control program.

Based on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, review of the Manufacturer’s Instructions for use of the Assure Platinum Blood Glucose Monitoring System and review of the facility’s policies, the facility failed to develop and implement an ongoing infection prevention and control program (IPCP) to prevent, recognize, and control the onset and spread of infection to the extent possible.

The facility failed to develop a water management program based on nationally accepted standards, specific to their building description, in order to prevent, detect and control water-borne contaminants and reduce Legionella growth. This had the potential to affect the entire population of the facility.

Observation of a fingersick revealed staff failed to clean the glucometer according to facility policy and the Manufacturer’s Instructions.

Observation of medication pass revealed that staff failed to clean the shared blood pressure cuff and the shared pulse oximeter after each patient use.

Observation of resident care revealed staff failed to don (put on) Personal Protective Equipment (PPE) before entering the room of a resident under contact precautions for shingles and a resident with enhanced barrier precautions.

Observation of staff revealed that staff failed to perform hand hygiene prior to resident care and passing out food.

Observation of resident care revealed that staff failed to empty a resident’s indwelling catheter in a manner to prevent contamination of the catheter spigot and possible infection.