LIBERTY, KY - Federal inspectors identified significant safety and care violations at Liberty Care and Rehabilitation Center following a June 2024 inspection that documented serious injuries to residents, including a severe hand fracture requiring emergency surgery and multiple instances of inadequate personal care.
Wheelchair Safety Failure Results in Severe Injury
The most serious incident involved a resident with severe dementia and cognitive impairment who sustained a devastating hand injury during routine transport in her specialized wheelchair. On June 9, 2024, two nursing aides were moving the 87-year-old resident back to her room when her left index finger became caught in the wheelchair spokes, resulting in multiple severe injuries.
The resident was immediately transported to the local hospital emergency department, where physicians discovered two significant lacerations. The larger wound measured 2.0 centimeters and exposed bone in the proximal region of the finger, while a second 1.5-centimeter laceration was located at the medial joint. Due to the severity of the injuries, the resident was transferred to a university hospital for evaluation by a hand specialist.
X-ray findings revealed the resident had sustained a significantly displaced comminuted angulated fracture of the proximal index finger - meaning the bone was broken at an angle and shattered into several pieces. The injury was classified as an open fracture, where the broken bone creates an open wound, and required immediate surgical intervention with a splint and bandage for stabilization.
Critical Care Planning Failures
Investigation revealed that facility staff were well aware of the resident's behavioral pattern of grabbing wheelchair wheels and spokes when she didn't want to be moved, yet this known safety risk was never addressed in her care plan. Multiple staff members, including licensed practical nurses and certified nursing aides, confirmed they regularly observed this behavior and had to repeatedly ask the resident to place her hands in her lap before moving her wheelchair.
Licensed Practical Nurse 5 explained that when the resident exhibited this behavior, she would "get down on her level and encourage her to put her hands in her lap." However, despite this known pattern, no safety interventions were documented in the resident's comprehensive care plan prior to the incident.
The facility only added spoke covers to the wheelchair after the injury occurred on June 11, 2024 - two days after the preventable accident. The Unit Manager acknowledged that the resident "should have been care planned for this behavior of grabbing the wheels, and interventions should have been in place to prevent injury related to this prior to the incident."
Inadequate Personal Hygiene and Daily Care
Inspectors also documented failures in basic personal care for residents unable to perform activities of daily living independently. Two residents were found to be receiving inadequate assistance with essential hygiene needs, raising serious concerns about dignity and health risks.
One resident with intact cognition but complete dependence for personal care complained that staff "had not brushed her teeth or swabbed her mouth, and she did not receive assistance with mouth care very often." During observation, inspectors noted the resident had white crust on her lips and mouth, smelled of urine, and had greasy, tangled, and matted hair. She was observed wearing the same clothing for multiple days.
The resident reported receiving only two bed baths per week, with her "privates washed only when she had a bowel movement." Facility records confirmed she received just eight complete bed baths and two partial baths over a 28-day period, falling short of daily hygiene assistance required for dependent residents.
A second resident with moderate cognitive impairment was observed over multiple days with long, dirty fingernails, an unshaved face, and wearing the same shirt consecutively. His teeth were covered with a gray film, indicating poor oral hygiene care.
Medical Implications of Hygiene Neglect
Poor oral hygiene in nursing home residents can lead to serious health complications beyond discomfort and dignity issues. Bacteria buildup in the mouth increases risk of pneumonia, particularly dangerous for elderly residents with compromised immune systems. Inadequate personal hygiene can cause skin infections, urinary tract infections, and social isolation.
Regular bathing and clothing changes are essential for preventing skin breakdown, especially for incontinent residents who face increased risk of pressure ulcers and skin infections. The accumulation of bacteria and moisture from inadequate hygiene practices can quickly progress to more serious medical conditions requiring hospitalization.
Failure to Update Care Plans After Safety Incidents
A pattern emerged of staff failing to revise care plans following safety incidents, potentially exposing residents to repeated risks. When a resident with a history of falls sustained another fall while searching in his closet, resulting in a skin tear to his right forearm, the facility documented the incident but failed to implement new preventive interventions.
The resident was found on his knees beside his closet door and told staff he "fell to his knees when searching for something in his closet." Despite his documented history of falls and cognitive impairment, no additional safety measures were added to his care plan to prevent similar incidents.
The facility's MDS Nurse admitted she was unaware the resident's fall had not been addressed with new interventions, stating "care plans were to be updated immediately following a fall in order to prevent recurrence."
Ongoing Behavioral Management Issues
Inspectors documented persistent problems with a resident who regularly entered other residents' rooms and handled their belongings, despite having a care plan addressing this behavior since December 2023. The resident was observed multiple times attempting to enter other rooms and going through personal items, including opening food containers that other residents subsequently had to discard.
Other residents complained about the ongoing intrusions. One resident stated the individual "wandered into her room several times per week and would go through her belongings," while another reported having to "hide away her perfumes" because the resident was seen trying to take them.
Staff acknowledged they were aware of the behavior but had not updated the care plan with additional interventions when initial approaches proved ineffective. The facility's MDS Nurse revealed she was unaware the behavior was continuing because "no behaviors were documented by staff" in the electronic medical record system.
Additional Issues Identified
The inspection revealed several other areas of concern that contribute to an overall pattern of inadequate care oversight. Staff communication gaps resulted in known safety risks not being properly documented or addressed through formal care planning processes. The facility's interdisciplinary team failed to convene timely meetings to address ongoing behavioral issues affecting multiple residents.
Documentation deficiencies were noted throughout the facility's record-keeping systems, with staff observations of concerning behaviors not being properly recorded in resident medical records. This created dangerous gaps between what staff observed and what was officially documented for care planning purposes.
The facility's policies for activities of daily living assistance lacked specific frequency requirements for oral care, contributing to inconsistent implementation of basic hygiene protocols across different shifts and staff members.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Liberty Care and Rehabilitation Center from 2024-06-14 including all violations, facility responses, and corrective action plans.
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