Liberty Care And Rehabilitation Center

F-F657)

During an interview with the Director of Nursing (DON), on 06/14/2024 at 9:06 AM, she stated she was notified of Resident R37's injury by LPN5. The DON stated after the resident was transferred to her bed, staff observed her finger was lacerated and injured, and the injury was caused by the wheelchair. The DON further stated prior to Resident R37's incident staff was trained on the use of all equipment in the facility, including all makes of wheelchairs, and to pay attention to the residents during transport and transfer. However, the DON could not provide any documented evidence staff was trained on the Evolution chair prior to Resident R37's accident.

In further interview, the DON stated Resident R37 liked to be in control and was non-compliant at times due to decreased cognition. She further stated staff was aware of this, as behaviors and non-compliance were reported at shift change and were in the resident's care plan. She further stated after the incident, Resident R37's wheelchair spokes were covered by maintenance to prevent her hands from getting caught in the spokes; and maintenance placed spoke covers on all specialty wheelchairs. Additionally, she stated the facility evaluated all residents who used wheelchairs for positioning and safety after the incident.

During an interview with the Corporate Nurse Consultant (CNC), on 06/14/2024 at 9:24 AM, she stated she was notified the morning of the incident regarding Resident R37's injury. The CNC stated the resident's finger was injured at some point during her transport to her room to provide care. She stated Resident R37 should have been care planned for grabbing the wheels during transport in order for staff to watch for this. She further stated

she expected staff to follow all safety procedures, and watch residents during transport and transfers to avoid injuries. The CNC stated it was important to provide a safe and comfortable environment for residents and to prevent accidents and injury to residents and staff.

The State Survey Agency Surveyor attempted to contact the Provider at the University Hospital on 06/14/2024 at 7:55 AM. During a conversation with the emergency department's Case Manager, she stated

she would have the Provider call. No return call was received.

During an interview with the Administrator, on 06/14/2024 at 9:24 AM, she stated she was notified of Resident R37's injury by the DON. The Administrator stated the injury was caused by the wheelchair. She further stated after

the incident the facility assessed all residents in wheelchairs for positioning and safety; and spoke covers had been placed on all specialty wheelchairs. The Administrator stated it was her expectation staff ensure important safety measures were in place in order to provide a safe and comfortable environment for residents. She stated this was important to prevent accidents and injury to residents and staff.

During an interview with the Medical Director, on 06/14/2024 at 1:10 PM, he stated he was informed about

the incident regarding Resident R37. He stated he was told the aide pulled the wheelchair in the opposite direction and

the resident's fingers were caught in the wheelchair spokes. He further stated he ordered the resident to be transferred to the ER. The Medical Director stated it was his expectation staff provide for the safety and well-being of the residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 42 185408 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185408 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Liberty Care and Rehabilitation Center 616 S Wallace Wilkinson Blvd Liberty, KY 42539

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 49267

Level of Harm - Actual harm 2. Record review revealed the facility admitted Resident #29 (Resident R29) on 04/10/2022 with diagnoses including dementia, Alzheimer's disease, and a history of falls. Residents Affected - Few

Review of Resident R29's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/08/2024, revealed the facility assessed the resident as having a BIMS score of six (6) out of 15, indicating severe cognitive impairment. Further review revealed the facility assessed the resident as requiring partial/moderate assistance for tub and shower transfers, toileting, chair to bed transfers, and sit to stand transfers. Additionally, the facility assessed Resident R29 for wheeling himself in a manual wheelchair after help being seated. Continued review revealed the facility assessed the resident as having a history of falls.

Review of Resident R29's Comprehensive Care Plan (CCP), revised on 05/10/2024, revealed the resident was identified as a fall risk with poor safety awareness on 04/10/2022. The goal stated the resident would not sustain an injury related to falls. An intervention for safety checks was initiated on 02/06/2024. Additional interventions in place included: bathroom light left on at night, non-slip socks as resident allowed, assistance to toilet as needed and limited/partial assistance with transfers.

Review of Resident R29's Progress Note, dated 06/10/2024, revealed Licensed Practical Nurse (LPN) 6 found the resident on his knees beside the closet door. Per the Note, Resident R29 told LPN6 he fell to his knees when searching for something in his closet. Further review revealed LPN6 noted a skin tear to the resident's right forearm (RFA) with no pain complaints. LPN6 cleaned and covered the skin tear, notified the physician, and notified Resident R29's family.

Review of the facility's Event Report, dated 06/10/2024, signed by Licensed Practical Nurse (LPN) 6, revealed Resident R29 sustained an unwitnessed fall. Further review revealed nursing performed an assessment and completed neurological checks; both with no significant findings.

Review of Resident R29's Physician's orders, dated 06/10/2024, revealed orders to cleanse skin tear to right forearm with normal saline, pat dry. Apply triple antibiotic ointment (TAO) and cover with abdominal (ABD) pad. Wrap area with kerlex daily until healed.

However, review of Resident R29's CCP, revealed no documented evidence of new interventions following Resident R29's 06/10/2024 documented fall in an attempt to reduce the resident's risk of recurrence.

Observation on 06/12/2024 at 10:43 AM revealed Resident R29 was resting in bed. The resident's right forearm was wrapped with gauze.

An interview was attempted with Resident R29 on 06/13/2024 at 2:00 PM, but the resident did not respond to questions.

During an interview with LPN6, on 06/13/2024 at 4:01 PM, she stated she was familiar with Resident R29's care and found him on the floor by his closet on 06/10/2024. LPN6 stated Resident R29 told her he was trying to get something from his closet. She stated she observed a skin tear to the resident's right forearm (RFA), so she notified the physician and Resident R29's family. The nurse stated she cleaned the area with normal saline, repositioned the skin back into place, and covered it with a dressing. She was unaware of any new interventions to prevent recurrence.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 42 185408 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185408 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Liberty Care and Rehabilitation Center 616 S Wallace Wilkinson Blvd Liberty, KY 42539

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 During an interview with the MDS Nurse, on 06/14/2024 at 1:27 PM, she stated resident care plans received updates with ARD assessments or as needed, such as with resident falls or changes in behavior. She further Level of Harm - Actual harm stated care plans were to be updated immediately following a fall with new interventions in order to prevent recurrence. Residents Affected - Few

During an interview with the Unit Manager (UM), on 06/13/2024 at 1:55 PM, she stated Resident R29 often displayed confusion. She stated the resident constantly asked staff, Why am I here? The UM stated resident falls were communicated during shift change to oncoming staff. The UM stated the MDS Nurse or any nurse could update the CCP when resident falls occurred. She stated care plans should be updated immediately with new interventions after a fall in order to attempt to prevent recurrence.

During an interview with the Director of Nursing (DON), on 06/14/2024 at 1:32 PM, she stated she performed random reviews to ensure staff revised care plans when changes or events such as falls occurred. She further stated she provided education as needed to staff based on concerns identified with the reviews.

In an interview with the Administrator, on 06/14/2024 at 3:18 PM, she stated she expected staff to ensure necessary interventions were in place to ensure resident safety in an attempt to prevent falls.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 42 185408 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185408 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Liberty Care and Rehabilitation Center 616 S Wallace Wilkinson Blvd Liberty, KY 42539

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or 50442 potential for actual harm Based on observation, interview, and review of the facility's policy, the facility failed to ensure residents Residents Affected - Few 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 (Resident R58).

Observation on 06/10/2024 and 06/11/2024, revealed Resident 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.

The findings include:

Review of the facility's policy titled, Oxygen Administration Policy, revised 05/30/2024, revealed oxygen tubing was to be changed monthly or as needed.

Review of Resident R58's electronic medical record (EMR) Face Sheet, revealed the facility admitted the resident on 05/06/2024 with diagnoses including congestive heart failure, dementia, benign prostatic hyperplasia, and atherosclerotic heart disease.

Review of Resident R58's Admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/13/2024, revealed the resident required continuous oxygen therapy.

Review of Resident R58's Physician's Orders, dated 06/11/2024, revealed orders for oxygen at two (2) liters per minute per nasal cannula; and oxygen tubing to be changed monthly.

Observation on 06/10/2024 at 3:13 PM; and 06/11/2024 at 9:13 AM, revealed Resident R58 receiving oxygen at two (2) liters per minute per nasal cannula. However, the oxygen tubing was not dated.

In an interview with Registered Nurse 1 (RN1), on 06/12/2024 at 2:23 PM, she stated nurse management changed the oxygen tubing. She stated the oxygen tubing should be dated.

In an interview with Licensed Practical Nurse (LPN) 3, on 06/13/2024 at 3:36 PM. she stated oxygen tubing was only changed by nursing management once a month. She further stated when the oxygen tubing was changed it should be dated.

In an interview with the Director of Nursing (DON), on 06/14/2024 at 8:45 AM, she stated oxygen tubing was changed by nursing management and was changed monthly. She further stated the tubing should be dated with the date it was changed. In continued interview, she stated she had noticed when new admissions were ordered oxygen, the nursing staff set up the oxygen and did not date the tubing.

In an interview with the Administrator, on 06/14/2024 at 9:21 AM, she stated nursing management changed

the oxygen tubing monthly. She stated oxygen tubing should be dated.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 42 185408 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185408 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Liberty Care and Rehabilitation Center 616 S Wallace Wilkinson Blvd Liberty, KY 42539

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm 50442

Residents Affected - Few 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 (Resident R322).

Resident 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.

Refer to

F-F689

The findings include:

Review of the facility's policy titled, Comprehensive Care Plans, revised 02/09/2024, revealed each resident's care plan was designed to incorporate identified problem areas, incorporate risk factors associated with identified problems, and were to be revised as necessary with changes.

1. Review of Resident R37's electronic medical record (EMR) Face Sheet revealed the facility admitted the resident on 12/09/2022, with diagnoses which included Alzheimer's disease, severe dementia with agitation, mood disturbances, psychotic disturbances, and cognitive communication deficit.

Review of Resident R37's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/24/2024, revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of two (2) out of fifteen, indicating severe cognitive impairment. Additional review revealed the facility assessed the resident as requiring substantial/maximal assist of two (2) for chair to bed, and bed to chair transfers and as independent with locomotion in a specialized wheelchair.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 42 185408 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185408 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Liberty Care and Rehabilitation Center 616 S Wallace Wilkinson Blvd Liberty, KY 42539

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Review of Resident R37's Comprehensive Care Plan (CCP), revised 05/24/2024, revealed a focus of Activities of Daily Living (ADL) with a goal stating the resident will regain ability for locomotion on and off the unit. Interventions Level of Harm - Actual harm related to locomotion included following Physical Therapy's (PT) and Occupational Therapy's (OT) recommendations related to ADLs and the correct use of the resident's mobility chair; and to allow the Residents Affected - Few resident extra time to complete ADLs. However, the care plan interventions did not list PT and OT recommendations for the correct use of the mobility chair.

Additional review of Resident R37's CCP, revised 05/24/2024, revealed a focus on behaviors, including demonstrates non-compliance with Physician's Orders and/or plan of care. The long term goal revealed the resident's preferences will be honored to the extent that non- compliance with the plan of care will not result in injury to self or others. Interventions created on 02/11/2024 included encourage resident to actively participate in the care plan and decision making; and encourage the resident's participation with care. Additional review of the CCP revealed the facility did not address the resident's habit of grabbing onto the wheelchair wheels and not moving her feet when being transported by staff in her specialized wheelchair. There were no safety interventions to prevent injury related to this behavior.

Review of the facility's Event Report - Change in Condition, dated 06/09/2024 at 12:52 AM, signed by Licensed Practical Nurse (LPN) 5, revealed while staff assisted Resident R37 to her room for routine care, the resident's finger was caught in the wheel spokes of the mobility chair causing injury to her left index finger. LPN5 assessed Resident R37 as having a skin tear with moderate blood noted. The resident's responsible party and physician were notified and the resident was transferred by emergency medical services (EMS) to the Hospital for further evaluation.

Review of Resident R37's local Hospital Emergency Department's Progress Note, dated 06/09/2024 at 1:38 AM, revealed physicians found (1) laceration, measuring 2.0 centimeters (cm) which exposed the bone in the proximal region of the finger, and another measuring 1.5 cm which was located at the medial joint. Per the Note, the resident was subsequently transferred to the University Hospital Emergency Department to seek evaluation by a hand specialist.

Review of Resident R37's University Hospital Physician Progress Notes, dated 06/09/2024 at 1:38 AM, revealed the patient (resident) presented to the emergency department for a higher level of care from an outside hospital to evaluate the left finger injury. The patient sustained an open fracture to her left index finger, with an approximate 2.0 cm laceration to the metacarpophalangeal joint, with deformity of the left hand noted.

Review of Resident R37's University Hospital X-ray findings, dated 06/09/2024, revealed the resident had a significantly displaced comminuted angulated fracture (when the bone is broken at an angle and into several pieces) of the proximal index finger with associated soft tissue swelling and significant soft tissue irregularity which is suggestive of an open fracture (a broken bone that causes an open wound).

Continued review of Resident R37's University Hospital's Emergency Department Progress Note, dated 06/09/2024, revealed the emergency department physician applied a bandage and short arm splint to the resident's left hand/arm for stabilization of the fracture. Per the Note, the University Hospital referred the patient to an orthopedic surgeon for follow-up care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 42 185408 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185408 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Liberty Care and Rehabilitation Center 616 S Wallace Wilkinson Blvd Liberty, KY 42539

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 On 06/11/2024, after the incident, the facility revised Resident R37's CCP to include an intervention to provide spoke covers to her wheelchair. Level of Harm - Actual harm

During an interview with State Registered Nurse Aide (SRNA) 4, on 06/12/2024 at 3:16 PM, she stated she Residents Affected - Few was agency staff and did not directly care for Resident R37 during her shift on 06/09/2024, but noticed the resident needed incontinence care. She stated she informed SRNA10 of this and offered to help. SRNA4 stated SRNA10 initially took hold of the wheelchair handles and began to push the wheelchair forward, and then SRNA10 instructed Resident R37 to remove her hands from the wheel spokes after she tried to push the wheelchair. SRNA4 stated after Resident R37 was instructed to do so, she placed her hands in her lap. SRNA #4 stated Resident R37 tended to grab the spokes part of the wheelchair when she did not want staff to move her. SRNA4 stated it was not until she and SRNA10 had transferred Resident R37 to her bed that she noticed Resident R37's finger was crooked and they called LPN5 to the resident's room. Per interview, Resident R37 was transferred out of the facility per Emergency Medical Services (EMS).

During follow up interview with SRNA4, on 06/14/2024 at 1:30 PM, SRNA4 was interviewed about SRNA10's handling of the specialty wheelchair while transporting Resident R37. SRNA4 stated SRNA10 initially pulled the chair backwards toward the resident's room at an angle and then pushed the chair into Resident R37's room.

During a telephone interview, with SRNA10, on 06/13/2024 at 4:12 PM, she stated she had worked at the facility for two (2) months as an agency SRNA and did not know Resident R37 well at the time of the incident. SRNA10 stated Resident R37 was sitting in her specialty wheelchair facing the day room, when SRNA4 informed her

the resident needed to be changed. SRNA10 stated she saw Resident R37's hands holding on to the wheelchair wheels and asked her to move her hands to her lap, which she did. SRNA10 stated there were no cuts on

the resident's hand when Resident R37 placed her arms in her lap. She then stated she pulled the wheelchair backwards toward room [ROOM NUMBER]. SRNA10 stated once she and SRNA4 transferred Resident R37 to her bed, she noticed the resident's finger did not look normal and called for the nurse, who immediately came to

the room. She further stated she stayed in the room until EMS left with the resident.

In continued telephone interview, on 06/13/2024 at 4:12 PM, with SRNA10, she was interviewed as to why

she pulled the chair backward. She explained the chair was hard to push forward, Resident R37 had a boot on her foot, and it was easier for her to pull the wheelchair backward the short distance from room [ROOM NUMBER] to 211. SRNA10 further explained she was afraid the resident would not move her foot, and there were no foot rests on the chair.

During an interview with LPN5, on 06/13/2024 at 8:52 AM, she stated after SRNA4 and SRNA10 took Resident R37 to her room on 06/09/2024, she heard them yell, Oh my gosh. Oh my gosh. She explained when she arrived at

the resident's room, she observed Resident R37's finger was turned and it looked as though there was one (1) laceration. She further stated she applied a pressure dressing and informed the resident's physician, Hospice, and Family Member (F)1 of the injury. Further, she stated the physician gave an order to send the resident to the hospital by EMS transport for evaluation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 42 185408 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185408 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Liberty Care and Rehabilitation Center 616 S Wallace Wilkinson Blvd Liberty, KY 42539

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 In continued interview with LPN5, on 06/13/2024 at 8:52 AM, she stated she was uncertain how the resident's finger was injured, but stated the resident's hand might have been caught in the spokes of the Level of Harm - Actual harm wheelchair. LPN5 stated, before the incident, Resident R37 had been sitting in her specialty wheelchair in the day room. Further, LPN5 stated Resident R37 tended to grip the wheels of her chair tightly when she did not want to move. Residents Affected - Few LPN5 further stated when Resident R37 exhibited the behavior of gripping the wheels, she would get down on her level and encourage her to put her hands in her lap. LPN5 further stated she was unsure if the resident was care planned for this pattern of behavior prior to the incident. However, she stated it would be important for staff to be aware of this behavior in order to ensure the resident did not have her hands in the wheel spokes prior to moving the resident in the chair. LPN5 stated changes to a resident's care plan were automatically updated in the system, and staff communicated changes verbally. She stated as soon as nursing made changes to a care plan, those changes appeared in the computer system used by the SRNAs.

During an interview with LPN3/Unit Manager (UM), on 06/13/2024 at 3:43 PM, she stated Resident R37 was often non-verbal and could be very non-compliant due to decreased cognition, especially when staff tried to provide care or transport her in her wheelchair. She stated when Resident R37 did not want to move, staff found it challenging to transport her as she would grab the wheels of the chair to resist being moved. She further stated staff had to encourage Resident R37 to place her hands in her lap. LPN3/UM stated Resident R37 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 that occurred on 06/09/2024. Additionally, she stated nurses should update care plans immediately with new interventions if increased behaviors were noted that could lead to injury. She stated the MDS Nurse was primarily responsible for making revisions.

During an interview with the MDS Nurse, on 06/14/2024 at 1:27 PM, she stated resident care plans reviewed and revisions made with each MDS assessment and as needed, such as when there was an incident such as a resident fall, injury or a change in behavior. The MDS Nurse stated all nurses updated care plans, but

she typically completed most care plan revisions. She stated she was made aware of behaviors, falls, injuries, and changes in resident's condition as this was discussed daily at their interdisciplinary meetings.

She further stated she was not made aware of Resident R37's tendency to grab the wheels and spokes of her wheelchair and therefore she did not revise the resident's care plan to address this prior to the resident sustaining the injury on 06/09/2024.

During an interview with the Director of Nursing (DON), on 06/14/2024 at 9:06 AM, she stated Resident R37 preferred to be in control and could sometimes be non-compliant due to decreased cognition. She stated staff was aware of Resident R37's behaviors as any non-compliance was reported during shift changes. The DON stated she was not aware of the resident's tendency to grip the wheels, place her hands in the spokes, or not move her feet when staff attempted to ambulate her. She stated if a resident exhibited these behaviors, this should be addressed in the care plan. The DON stated it was important for the nurses to ensure care plans included necessary safety interventions and were revised as needed in order to ensure a safe and comfortable environment for the residents. In further interview, she stated this was important to prevent accidents and injury to residents and staff.

During an interview with the Administrator, on 06/14/2024 at 3:18 PM, she stated she expected staff to update care plans as needed as this was important in providing resident centered care. The Administrator further stated it was her expectation staff ensure care plans included important safety measures in order to provide a safe and comfortable environment for residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 42 185408 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185408 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Liberty Care and Rehabilitation Center 616 S Wallace Wilkinson Blvd Liberty, KY 42539

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 49267

Level of Harm - Actual harm 2. Review of Resident R29's electronic medical record (EMR) Face Sheet, revealed the facility admitted the resident

on 04/10/2022 with diagnoses to include dementia, Alzheimer's disease, and a history of falls. Residents Affected - Few

Review of Resident R29's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/08/2024, revealed the facility assessed the resident to have a BIMS score of six (6) out of 15, indicating severe cognitive impairment. Continued review revealed the facility assessed the resident as requiring partial/moderate assistance for tub and shower transfers, toileting, chair to bed transfers, and sit to stand transfers. Additional review revealed Resident R29 wheeled himself in a manual wheelchair after help being seated and had a history of falls.

Review of Resident R29's Comprehensive Care Plan (CCP), revised 05/10/2024, revealed the resident was identified as a fall risk with poor safety awareness. The goal revealed the resident would not sustain an injury related to falling. Interventions included safety checks, bathroom light left on at night, non-slip socks as resident allowed, assistance to toilet as needed and limited/partial assistance with transfers.

Review of the Progress Note, dated 06/10/2024, revealed Licensed Practical Nurse (LPN) 6 found Resident R29 on his knees beside the closet door. Resident R29 told LPN6 he fell to his knees when searching for something in his closet. Continued review revealed LPN6 noted a skin tear to the resident's right forearm (RFA) with no pain complaints. LPN6 cleaned and covered the skin tear, notified the physician, and notified Resident R29's family.

Review of the facility's Event Report, dated 06/10/2024, entered by Licensed Practical Nurse (LPN) 6, revealed Resident R29 sustained an unwitnessed fall. Further review revealed nursing performed an assessment and completed neurological checks; both with no significant findings.

Review of Resident R29's Physician's orders, dated 06/10/2024, revealed orders to cleanse skin tear to RFA (right forearm) with normal saline, pat dry. Apply triple antibiotic ointment (TAO) and cover with abdominal (ABD) pad. Wrap area with kerlex daily until healed.

However, review of Resident R29's CCP, revealed no updates with new interventions following Resident R29's 06/10/2024 documented fall, in an attempt to reduce the resident's risk of recurrence.

Observation of Resident R29 on 06/12/2024 at 10:43 AM, revealed the resident was resting in bed and his right forearm was wrapped with gauze.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 42 185408 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185408 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Liberty Care and Rehabilitation Center 616 S Wallace Wilkinson Blvd Liberty, KY 42539

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 In an interview with LPN6, on 06/13/2024 at 4:01 PM, she stated she found Resident R29 on the floor by his closet on 06/10/2024. She further stated he was on his knees banging on a drawer. LPN6 stated the resident told her Level of Harm - Actual harm he was trying to get something from his closet. LPN6 further stated the resident sustained a skin tear to the right forearm (RFA), and she notified the physician and Resident R29's family. In continued interview, LPN6 stated she Residents Affected - Few did not know if Resident R29's care plan was updated after the 06/10/2024 fall with new interventions, but if there was

a fall, there should be a new intervention placed on the care plan in order to prevent the resident from falling again. She stated changes to a resident's care plan automatically showed in the system, but staff communicated changes verbally. She further stated as soon as nursing made changes to a care plan, those changes showed in the computer system the Certified Nursing Assistants (CNAs) utilized.

During an interview with the MDS Nurse, on 06/14/2024 at 1:27 PM, she stated resident care plans received updates with MDS assessments or as needed, such as with resident falls, changes in behavior, or incidents.

She further stated care plans were to be updated immediately following a fall in order to prevent recurrence.

The MDS Nurse stated all nurses updated care plans, but she typically completed most care plan revisions.

She was unaware Resident R29's 06/10/2024 had not been care planned for a new intervention to prevent recurrence.

During an interview with the Unit Manager (UM), on 06/13/2024 at 1:55 PM, she stated care plans should be updated immediately with new interventions after a fall in order to prevent recurrence. The UM stated all nurses updated care plans, but the MDS Nurse primarily made revisions.

In an interview with the Director of Nursing (DON), on 06/14/2024 at 1:32 PM, she stated the MDS Nurse as well as other nurses could update the care plans and it was her expectation care plans were updated with changes in condition or behavior, or events such as falls. The DON further stated she performed random reviews to ensure staff revised care plans when changes or events occurred. Additionally, she stated she provided education as needed to staff based on concerns identified with the reviews.

During an interview with the Administrator on 06/14/2024 at 3:18 PM, she stated it was her expectation nursing staff updated care plans after a fall.

50442

3. Review of Resident R49's electronic medical record (EMR) Face Sheet revealed the facility admitted the resident on 09/28/2023 with diagnoses to include dementia and cognitive communication deficit.

Review of Resident R49's Comprehensive Care Plan, 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. The goal stated the resident will have decreased episodes of entering others room. Interventions included: resident will become involved in activities; remind resident not to enter others rooms and take their belongings; remind resident where her room is located; and Social work/psych evaluation. All interventions were initiated on 12/07/2023.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 42 185408 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185408 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Liberty Care and Rehabilitation Center 616 S Wallace Wilkinson Blvd Liberty, KY 42539

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Review of Resident R49's most recent Quarterly MDS dated [DATE REDACTED], with an ARD of 10/01/2023 revealed the facility assessed the resident as having a BIMS' score of two (2) out of 15 indicating severe cognitive impairment. Level of Harm - Actual harm Further review revealed the resident could only understand simple, direct phrases and could not recall any of

the three (3) words given in the short term memory test. Continued review revealed the facility assessed the Residents Affected - Few resident as not exhibiting wandering behaviors.

Review of Resident R49's Progress Note, dated 05/28/2024 at 10:00 AM, revealed she was seen trying to enter the room of another resident.

However, review of Resident R49's EMR in the Point of Care (POC) section, revealed the resident had no charted behaviors for the previous month (05/13/2024 through 06/13/2024)

Review of Resident R49's Progress Note, dated 05/29/2024 at 9:54 AM, revealed the Interdisciplinary Team met and discussed the event of 05/28/2024. No new orders were implemented.

Review of Resident R49's care plan revealed the last conference was on 04/24/2024 and the next care conference was projected for 07/23/2024. No revisions were made to the CCP related to the resident's behaviors of entering other residents' rooms since the initial problem was care planned on 12/07/2023.

Observation of Resident R49 on 06/11/2024 at 10:22 AM, revealed the resident was trying to enter Resident R4's room. Resident R49 was redirected away from the entrance of Resident R4's door by staff.

Observation of Resident R49 on 06/12/2024 at 2:18 PM, revealed the resident was trying to enter the locked soiled utility room. She was rolling down the hallway in her wheelchair and stopped and tried to push open the door.

In an interview with Resident R26, on 06/10/2024 at 2:43 PM, she stated Resident R49 wandered into her room several times per week and would go through her belongings. Resident R26 stated Resident R49 opened a box of cookies and touched them, but did not take or eat them. Resident R26 further stated she threw them away afterwards.

In an interview with Resident R4, on 06/12/2024 at 9:44 AM, she stated Resident R49 frequently came in her room, and the last time this occurred was the prior week. She stated she had to hide away her perfumes because Resident R49 was seen trying to take them.

In an interview with State Registered Nurse Aide (SRNA) 6, on 06/12/2024 at 11:13 AM, she stated Resident R49 did try to enter other resident rooms, and when she observed this, she would stop and redirect the resident to another area.

In an interview with SRNA7, on 06/12/2024 at 11:17 AM, she stated Resident R49 did try to wander into other residents' rooms, and when she observed this she would redirect the resident to another area or activity and sometimes offer the resident food. She stated when she saw Resident R49 repeatedly trying to enter other residents' rooms, she reported the behavior to her nurse.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 42 185408 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185408 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Liberty Care and Rehabilitation Center 616 S Wallace Wilkinson Blvd Liberty, KY 42539

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 In an interview with Licensed Practical Nurse #1 (LPN1), on 06/12/2024 at 11:29 AM, she stated when Resident R49 was wandering in the hallway, she tried to keep a close eye on her. LPN1 stated when Resident R49 tried to enter Level of Harm - Actual harm another resident's room, she would redirect her and find a diversionary activity. She stated she was unsure what interventions were care planned for Resident R49. Further, she stated Resident R49 had behaviors of wandering and Residents Affected - Few entering other residents' rooms because she had a need that was not met, and she was looking for something that she needed. She stated, for example, after lunch, Resident R49 would sometimes enter someone else's room, and it was most likely because she was looking for a bathroom.

During continued interview with LPN1, on 06/12/2024 at 11:29 AM, she stated she watched Resident R49 and then would try and anticipate what needs were not being met and meet those needs to prevent the wandering behavior from increasing. LPN1 stated if Resident R49's behaviors were escalating, she would inform the Unit Manager. In further interview, LPN1 stated it would be up to the Interdisciplinary Team (IDT) and the facility's Medical Director to modify interventions to prevent behaviors. The nurse stated there was one (1) resident who had a stop sign on his door and Resident R49 was not observed trying to enter his room. LPN1 stated the stop sign deterred Resident R49; however, other residents did not like the stop sign on their doors.

In an interview with Registered Nurse (RN)1, on 06/12/2024 at 2:28 PM, she stated Resident R49 had to be diverted away from other residents' rooms. RN1 stated Resident R49 wandered into other resident rooms in search of something that she needed. She stated she tried to prevent this wandering behavior when she noted it by trying to find out what Resident R49 needed.

In an interview with LPN3/Unit Manager, on 06/13/2024 at 3:37 PM, she stated she had offered the stop signs to residents when Resident R49 entered their rooms, but the residents refused them. She stated current interventions in place to prevent Resident R49 from wandering into the rooms of others and getting into their possessions was to watch Resident R49 and prevent her from entering other residents' rooms, and then redirect her to another area and engage her with a diversionary activity.

In an interview with the MDS Nurse, on 06/13/2024 at 2:45 PM, she stated she was not aware Resident R49 was still wandering and entering the rooms of other residents and this was why the resident's CCP had not been revised with new interventions. She stated when she looked in Resident R49's EMR in the Point of Care (POC) section, no behaviors were documented by staff. She stated if she had known Resident R49 was still exhibiting behaviors of entering other residents' rooms she would have had staff do a stop and watch. Per interview, that was when a resident was placed one (1) on one (1) with a staff member to see if and when the behaviors were occurring. She further stated the Administrator, Social Services, and the Psychology Nurse Practitioner along with the IDT would need to work on interventions to prevent Resident R49's behaviors. She stated

the stop sign was a deterrent for Resident R49 and offering stop signs to other residents might be an intervention to help prevent Resident R49 from entering their rooms.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 42 185408 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185408 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Liberty Care and Rehabilitation Center 616 S Wallace Wilkinson Blvd Liberty, KY 42539

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 In an interview with the DON, on 06/14/2024 at 8:41 AM, she stated the facility had tried to get Resident R49 involved

in activities to prevent her from wandering, but due to her dementia she had a short attention span, and it Level of Harm - Actual harm was difficult. She further stated if getting Resident R49 to participate in activities was not conducive to keeping her out of other residents' rooms, then she may need to be placed one (1) on one (1) with someone. That individual Residents Affected - Few would watch her and keep her out of other residents' rooms. In continued interview, she stated the facility had spoken with her son to see what things Resident R49 enjoyed, and they had tried to incorporate those into her activities. She further stated the care plan needed to be revised to include other interventions such as new activities in an attempt to prevent the resident from wandering into other residents' rooms. She stated Resident R49 did not enter the room with the stop sign. She said they may have to offer it to residents such as Resident R4 and R 26.

In an interview with the Administrator, on 06/14/2024 at 9:08 AM, she stated it was unfair for other residents to have their room entered and their belongings gone through or taken. She stated when the care planned interventions did not work for preventing a resident from entering the rooms of others, the IDT needed to get involved and revise the care plan to address the behavior. She stated Resident R49 would be placed on one (1) on one (1) supervision with a staff member.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 42 185408 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185408 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Liberty Care and Rehabilitation Center 616 S Wallace Wilkinson Blvd Liberty, KY 42539

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable.

Level of Harm - Minimal harm or 50442 potential for actual harm Based on observation, interview, record review, and review of facility policy, it was determined the facility Residents Affected - Few 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 (Resident R55 and Resident R58).

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

The findings include:

Review of the facility's policy titled, Activities of Daily Living (ADLs), created on 09/15/2023, revealed ADL assistance would be provided on a level appropriate to the resident's level of functioning and learning and/or

the responsible party's level of support and contribution to resident care. For residents who were unable to perform their own activities of daily living, the facility will provide the needed assistance for completion of care.

Review of the facility's policy titled, Oral Care, last reviewed on 07/05/2018, gave guidelines for oral and denture care. The policy did not mention the frequency of oral care.

1. Review of Resident R55's electronic medical record (EMR) Face Sheet revealed the facility admitted the resident on 12/27/2023 with diagnoses including essential primary hypertension, depression, and generalized muscle weakness.

Review of Resident R55's Quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 05/18/2024, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated intact cognition. Further review of the MDS, revealed the facility assessed the resident to be dependent for eating, oral hygiene, toileting hygiene, showering/bathing, dressing her lower body, putting on/taking off footwear, and personal hygiene. Continued review revealed the resident required substantial/maximal assistance for dressing her upper body.

Review of Resident R55's Comprehensive Care Plan, dated 05/22/2024, revealed a focus of requiring assistance with ADLs. The goal stated the resident will not further deteriorate related to ADL ability as evidenced by maintaining current ability with potential for improvement. The interventions included: provide extensive assistance with dining and bed mobility; use mechanical lift for transfers; provide total assistance with locomotion in wheelchair; and total assistance with personal hygiene/grooming. Resident R55's Comprehensive Care Plan did not indicate there was a problem of refusing assistance with ADLs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 42 185408 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185408 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Liberty Care and Rehabilitation Center 616 S Wallace Wilkinson Blvd Liberty, KY 42539

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Review of Resident R55's EMR, under the Point of Care (POC) History section, revealed from 05/12/2024 to 06/09/2024, Resident R55 received eight (8) complete bed baths; and two (2) partial bed baths. One (1) refusal for Level of Harm - Minimal harm or assistance with ADLs was documented on the Non-Compliance-Informed Refusal and Non-Compliance potential for actual harm Event Report, during this time.

Residents Affected - Few Observation on 06/11/2024 at 8:38 AM, revealed Resident R55 had white crust on her lips and mouth. She smelled of urine and was dressed in a white long-sleeved shirt and a brief only. Resident R55's hair was greasy, tangled and matted.

Observation on 06/12/2024 at 10:03 AM, revealed Resident R55 was still dressed in the same white shirt as the day before. She smelled like urine. Her hair was still greasy, tangled, and matted and did not look like it had been combed. Her lips and mouth still had patches of white crust.

In an interview with Resident R55, on 06/12/2024 at 10:03 AM, she stated staff had not brushed her teeth or swabbed her mouth, and she did not receive assistance with mouth care very often. Resident R55 stated she was given a bed bath twice a week and her privates were washed only when she had a bowel movement. Resident R55 stated she was bed bound and staff did not take her to the shower.

2. Review of Resident R58's electronic medical record (EMR) Face Sheet revealed the facility readmitted the resident

on 05/24/2024 with diagnoses including congestive heart failure, dementia, and benign prostatic hyperplasia (BPH).

Review of Resident R58's Admission Minimum Data Set (MDS) with an ARD date of 05/13/2024, revealed the facility assessed the resident as having a BIMS' score of 12 out of 15, indicating moderate cognitive impairment. Further review of the MDS revealed the facility assessed the resident as dependent for transfers from bed to chair and in and out of the shower. Continued review revealed the facility assessed the resident as always incontinent of bowel and bladder.

Review of Resident R58's Comprehensive Care Plan, dated 05/24/2024 revealed a focus of requiring assistance with ADLs. The goal stated the resident will not experience any adverse outcomes related to requiring assistance with ADL care through next review. Interventions included: have resident perform as much of his own care as

he could, but provide the amount of assistance needed to complete ADLs; total assistance with the mechanical lift for transfers; and assist with showers and incontinence care.

Review of R 58's EMR, under the Point of Care (POC) History, revealed from 05/12/2024 to 06/09/2024, the resident received five (5) complete bed baths; and one (1) partial bed bath approximately every three (3) to five (5) days. No refusals were documented.

Observation of Resident R58, on 06/10/2024 at 3:02 PM, revealed he had long, dirty fingernails. The resident was wearing a dark gray shirt.

Observation of Resident R58 on 06/11/2024 at 9:07 AM, revealed he was still wearing the same shirt as the day before. He was still not shaved, his teeth were covered with a gray film, and his fingernails were still long and dirty.

In an interview with Resident R58, on 06/10/2024 at 3:02 PM, he stated he was unable to answer questions related to his care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 42 185408 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185408 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Liberty Care and Rehabilitation Center 616 S Wallace Wilkinson Blvd Liberty, KY 42539

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Interview with State Registered Nurse Aide (SRNA)5, on 06/12/2024 at 10:32 AM, revealed residents were showered twice per week and received bed baths on days they were not showered. Further, oral care was to Level of Harm - Minimal harm or be performed daily. If a resident refused help or performance of ADLs, she would let the nurse know, and potential for actual harm then would try again later or ask another staff member to perform the care. If the resident still refused, she charted the refusal. Residents Affected - Few

In an interview with SRNA7, on 06/12/2024 at 11:07 AM, she stated she assisted her assigned residents with

a shower according to the daily shower schedule, which she received in the morning report from her nurse.

She stated she was not sure how many times per week residents were showered. She further stated she helped residents with their ADLs who wanted to go to breakfast in the dining room first in the morning, and then afterwards moved on to assist residents who ate in their room. In continued interview she stated she ensured residents received oral care daily, and assisted residents with getting dressed and combed their hair every morning. Further, she stated she did rounds on residents every two (2) hours checking for anyone who was incontinent and needed care.

In an interview with Licensed Practical Nurse (LPN)1, on 06/12/2024 at 11:29 AM she stated if residents were able to perform some of their ADLs, she allowed them to do as much as they could and would assist with what they were unable to do. She stated residents were to receive showers twice a week unless it was

in their care plan for more frequent showers or to only give them a bed bath. Per interview, it was her expectation SRNAs give bed baths on days showers were not performed. She further stated it was her expectation oral care be performed a minimum of once per day, but ideally should be done in the morning,

after meals, and at night.

In an interview with Registered Nurse #1(RN1)1, on 06/12/2024 at 2:28 PM, she stated each day she gave her SRNAs a printed census of which residents were to be assisted out of bed in the mornings first, because

they wanted to go to breakfast in the dining room. She stated the census list also showed which residents were due for a shower that day. Per interview, residents who ate breakfast in their rooms received help with their ADLs later in the morning. Further, she stated residents were to receive two (2) showers a week, and partial baths in between. RN1 stated she assured residents received oral care at least daily, and more frequently if needed. She stated she did now know how often SRNAs did rounds on their residents to check for incontinence, but stated it was frequently.

In an interview with LPN3/Unit Manager, on 06/13/2024 at 3:31 PM, she stated the residents' shower schedules were set up upon admission. Showers were to be completed twice a week, but could also be given upon request. She stated residents received bed baths daily or upon request; oral care was performed each shift; nail care was performed every Sunday; and male residents received shaves on shower day or upon request. LPN3/Unit Manager stated refusal of care such as bathing, shaving, or oral care was documented. She further stated it was her expectation SRNAs made rounds on residents every two (2) hours to check for incontinence. Additionally, she stated any refusals of care were charted on a noncompliance form and followed for three (3) days afterwards. LPN3/Unit Manager stated she was unaware Resident R55 and Resident R58 were not receiving assistance needed with ADL care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 42 185408 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185408 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Liberty Care and Rehabilitation Center 616 S Wallace Wilkinson Blvd Liberty, KY 42539

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 In an interview with the Directive of Nursing (DON), on 06/14/2024 at 8:22 AM, revealed residents were expected to perform as much of their ADLs as they were able and nursing staff would assist with the rest of Level of Harm - Minimal harm or the care. She stated residents were to receive showers or baths at least twice a week, but the shower/bath potential for actual harm schedule was individualized for each resident. She stated staff was to help residents wash up in between showers. In interview, she stated oral care was to be performed every shift and residents were to have their Residents Affected - Few clothes changed daily, and their hair should be brushed at least daily. Further, she stated male residents should be shaved daily as they would allow. She stated staff was to check on the residents at least every two (2) hours to check for incontinence.

In an interview with the Administrator, on 06/14/2024 at 8:58 AM, she stated complete baths or showers were to be given at least twice a week, and residents were to receive partial baths in between their total baths/showers. Further, she stated staff was to assist residents with oral care after each meal, and nail care was to be performed on shower day and as needed. She further stated shaving for male residents depended

on the wishes of the resident as some residents preferred not to be shaved every day. The Administrator stated nursing staff was to round on the residents every two (2) hours or more frequently to check to see if incontinence care was needed. Further, she stated residents were to have their hair combed daily and their clothes changed daily unless the resident refused. Any care that was refused was documented on a noncompliance form.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 42 185408 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185408 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Liberty Care and Rehabilitation Center 616 S Wallace Wilkinson Blvd Liberty, KY 42539

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44001 Residents Affected - Few 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), Resident R29 and Resident R37.

On 06/09/2024, during transfer back to Resident 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. Resident 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, Resident 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.

Refer to

F-F761.

The findings include:

Review of the facility's policy titled, Medication Administration, General Guidelines, revealed medications were to be prepared only by licensed medical or pharmacy personnel authorized by state regulations to prepare medicine.

Review of Resident R322's electronic medical record (EMR) Face Sheet revealed the facility admitted the resident on 06/07/2024 with a diagnosis of latent tuberculosis (TB).

Review of Resident 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.

Review of the Shipping Manifest from the pharmacy, dated 06/07/2024, revealed it did not list the rifampin.

Review of the Shipping Manifest from the pharmacy, dated 06/10/2024, revealed thirty (30) rifampin 300 mg tablets, arrived at the facility on that date at 8:15 PM, which was after the scheduled administration time for

the medication.

Review of 322's Medication Administration Record (MAR), dated June 2024, revealed the resident did not receive the medication on 06/08/2024, 06/09/2024, or 06/10/2024 as the medication was unavailable.

In an interview with Registered Nurse (RN)1, on 06/13/2024 at 9:53 AM, revealed Resident R322 did not receive the rifampin on 06/08/2024, 06/09/2024, or 06/10/2024, because the pharmacy was out of the medication.

In an interview with the Staff Development/Infection Control RN, on 06/13/2024 at 10:29 AM, she stated the facility was unable to obtain the rifampin medication for Resident R322, until four (4) days after it was ordered. Further

interview revealed it would be important to ensure rifampin was administered as ordered for the resident's diagnosis of latent TB.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 42 185408 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185408 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Liberty Care and Rehabilitation Center 616 S Wallace Wilkinson Blvd Liberty, KY 42539

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 In an interview with the Director of Nursing (DON), on 06/14/2024 at 8:49 AM, and the Administrator on 06/14/2024 at 9:14 AM, they both stated they were unaware of the delay in receiving the prescribed rifampin Level of Harm - Minimal harm or from their pharmacy for Resident R322. potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 42 185408 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185408 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Liberty Care and Rehabilitation Center 616 S Wallace Wilkinson Blvd Liberty, KY 42539

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or 50442 potential for actual harm Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure Residents Affected - Few residents were free of significant medication errors for one (1) of 42 sampled residents, Resident 332 (Resident R322).

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

The findings include:

Review of the facility's policy titled, Medication Administration General Guidelines, revealed medications were to be administered in accordance with written orders of the prescriber. Further review revealed those giving a medication should verify the medication is correct three (3) times before administering: when pulling

the medication package from the medication cart, when the dose was prepared, and before the dose was administered.

Review of Resident R322's electronic medical record (EMR) Face Sheet revealed the facility admitted the resident on 06/07/2024 with a diagnosis of latent tuberculosis (TB).

Review of Resident R322's Physician's orders, dated 06/07/2024, revealed orders for rifampin 300 milligrams (mg), two (2) tablets, to be given daily between 7:00 AM and 11:00 AM.

Review of the Shipping Manifest from the pharmacy, dated 06/10/2024 at 8:15 PM, revealed thirty (30) rifampin tablets, each 300 mg were received on that day.

Observation of the medication pass on 06/13/2024 at 9:00 AM with Registered Nurse (RN)1, revealed the nurse only administered Resident R322 one (1) 300 mg rifampin tablet.

Observation of the rifampin tablets count on 06/13/2024 at 10:45 AM with the Staff Development/Infection Control RN and RN1, revealed there were twenty-six tablets left. The Medication Administration Record (MAR), dated June 2024, revealed R 322 had been administered his daily dose of rifampin for three (3) days, including 06/11/2024, 06/12/2024, and 06/13/2024. Therefore, the bottle of rifampin should have had six (6) tablets missing to account for the three (3) days of medication administration. However, instead the count was observed to have only four (4) tablets missing.

Review of Registered Nurse (RN) 1's employee personnel file, revealed she was an agency nurse and had passed a written medication administration test upon hire as a part of her orientation on 05/23/2024, and also passed a skills check off on medication administration.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 42 185408 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185408 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Liberty Care and Rehabilitation Center 616 S Wallace Wilkinson Blvd Liberty, KY 42539

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 In an interview with the Staff Development/Infection Control RN, and RN1 on 06/13/2024 at 10:29 AM, they were asked to review Resident R322's orders with the State Survey Agency (SSA) Surveyor. Both nurses verbalized Level of Harm - Minimal harm or the resident was to receive two (2) of the 300 mg rifampin tablets per day. The Staff Development/Infection potential for actual harm Control RN stated if an incorrect dosage of rifampin was administered to Resident R322, the dose might not be therapeutic for treatment of the resident's latent TB. The Staff Development/Infection Control RN stated she Residents Affected - Few would give the second pill of today's dose and contact the physician to notify him of the medication error. In further interview, both nurses verbalized the reason the medication was not sent from pharmacy until 06/10/2024, even though it was ordered on 06/07/2024, was because their pharmacy/supplier was out of the medication.

In an interview with the Director of Nursing (DON), on 06/14/2024 at 8:49 AM, she stated medication administration training for new nurses and agency nurses was completed prior to the nurse administering medication at the facility. She stated this included a written medication administration test; and then another staff member observed them on medication pass to make sure they were competent. The DON stated medication errors were to be reported to the Medical Director and the resident observed for any signs of complications.

In an interview with the Administrator, on 06/14/2024 at 9:14 AM, she stated newly hired nurses were given a written test for medication administration and then they had to pass a check off competency for medication administration. During further interview she stated medications errors such as this error related to the resident not receiving the scheduled rifampin as ordered was to be reported to the physician and the resident monitored.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 42 185408 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185408 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Liberty Care and Rehabilitation Center 616 S Wallace Wilkinson Blvd Liberty, KY 42539

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 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 Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44001 Residents Affected - Few 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 REDACTED] at 10:15 AM, revealed two (2) opened vials of Insulin Glargine U100 with no opened date.

The findings include:

Review of the facility's policy titled, Medication Storage, dated 2007, revealed the purpose of the policy was to ensure medications and biological's were stored properly, following the manufacturer's or the provider's pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. Per

the policy, medications should remain in packaging provided by the pharmacy.

Observation of the North Wing's A-C Medication Cart, on [DATE REDACTED] at 10:15 AM, revealed two (2) opened vials of Insulin Glargine U100 which were not marked with the opened date.

During an interview with Licensed Practical Nurse #1 (LPN1), on [DATE REDACTED] at 12:30 PM, revealed the nursing staff was responsible for managing the medication carts and storage rooms. LPN1 stated nursing staff should record the date medication was opened on the insulin vial and box in which in was packaged. The LPN stated if staff find opened medications without an open date or expired medicines, they should dispose of them according to policy. She stated properly labeling and storing medication was essential for the safety of the residents.

During interview with LPN3/Unit Manager (UM), on [DATE REDACTED] at 10:35 AM, she stated the nursing staff was responsible for making sure medications were labeled according to the facility's process, which included recording the opened date on the medication. According to LPN/UM3, the pharmacy provided resources regarding the proper storage of insulin. She stated if a medication was found to be expired, or improperly labeled, the nursing staff should dispose of it according to policy. LPN3/UM stated she routinely conducted audits of all medication carts. Additionally, she stated the importance of storing all medications according to

the manufacturer's guidelines was to ensure the safety of the residents.

During an interview with the Director of Nursing (DON) on [DATE REDACTED] at 9:06 AM, she stated the nurses were responsible for stocking the medication carts and ensuring appropriate storage of medications. Per interview, nurses should store all medicines in their original packaging and date them when opened. She stated solutions were to have an opened date and an expiration date on the packaging and the bottle or vial. The DON stated if staff found any medication labeled, stored improperly, or expired, they should discard it. She stated it was important to ensure nurses labeled medications according to facility policy, which included recording the date opened on the packaging and medication container to prevent medication errors, wasting medications, and using potentially expired medicine.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 42 185408 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185408 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Liberty Care and Rehabilitation Center 616 S Wallace Wilkinson Blvd Liberty, KY 42539

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 During an interview with the Registered Pharmacist (RPH), on [DATE REDACTED] at 3:16 PM, he stated medications should be stored in their original packaging from pharmacy and according to the manufacturer's guidelines. Level of Harm - Minimal harm or He further stated nursing staff should follow facility policies regarding dating opened containers to ensure the potential for actual harm efficacy of the medications and biological's.

Residents Affected - Few During an interview with the Administrator, on [DATE REDACTED] at 3:18 PM, she stated it was her expectation for medications to be stored and labeled appropriately per the directives from the manufacturer's guidelines and

the facility's policies. She further stated it was important to follow guidelines and policies to ensure the safety of the residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 42 185408 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185408 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Liberty Care and Rehabilitation Center 616 S Wallace Wilkinson Blvd Liberty, KY 42539

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44001 potential for actual harm Based on observation, interview, record review, review of the Centers for Disease Control and Prevention Residents Affected - Some (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.

The findings include:

1. Review of the facility's policy titled, Water Management Plan, reviewed 01/2020, revealed the facility would have a water management program in place to prevent, detect and control water-borne contaminants. Furthermore, documentation for all aspects of the water management program will be maintained within the maintenance logs. Per policy, the facility would review the Water Management Plan annually.

Review of the CDC's Guidelines titled Developing a Water Management Program to Reduce Legionella Growth & Spread in Buildings, reviewed 06/2021, revealed facilities should develop a water management program to reduce Legionella growth and spread that was specific to their building description. Per the guidelines, the facility's plan should include details such as where the building connects to the municipal water supply, how water was distributed throughout the building, to include if applicable, where pools and hot tubs, cooling towers, and water heaters or boilers are located.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 42 185408 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185408 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Liberty Care and Rehabilitation Center 616 S Wallace Wilkinson Blvd Liberty, KY 42539

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Review of the facility's document titled, Legionella Water Plan Management, revealed the flow diagram provided by the Plant Operation Director (POD) only depicted the water flow from the building's front entry to Level of Harm - Minimal harm or the North Wing and South Wing mechanical rooms, but did not include the source of the water (e.g., potential for actual harm municipal water company). Furthermore, the plan and flow diagram did not address the distribution of cold water, including ice machines, sinks, or showers, and how hot water flowed through the system to reach Residents Affected - Some sinks and showers throughout the building. Further, the documentation stated Legionella growth was only possible in the water heaters located in the North and South Wings, but did not consider other potential locations such as low use sinks, showers, eye wash stations, kitchen appliances, or ice machines. Additionally, the facility did not outline in the plan how it would address situations where control limits were not met, stating only the Tels Program would be used to intervene.

During an interview with the Plant Operations Director (POD), on 06/11/2024 at 1:10 PM, the State Survey Agency (SSA) Surveyor requested a water system process flow diagram. The POD stated the facility did not have a detailed water flow diagram. He further stated he was not aware of the requirement for the facility water plan or the assessment to include the building's water systems flow diagram for identification of Legionella. Furthermore, he stated he was not familiar with the CDC's tool kit to assist facilities to develop and implement a water management program. According to the POD, the Tels Program was a building management system, which tracked preventive maintenance tasks, and kept records of water temperature testing and when to test the water, but it did not identify hazardous conditions.

During an interview with the Administrator, on 06/14/2023 at 9:12 AM, she stated it was her expectation the facility followed the CDC's recommendations and guidelines related to infection prevention and control practices. Further, she stated it was important to have a facility water management plan as part of the overall infection control plan, in order to reduce the risk of Legionnaire's disease and to identify potential areas where Legionella could grow and spread.

2. Review of the facility's policy titled, Glucometer Cleaning and Disinfecting, revised 01/2024, revealed the purpose of the policy is to minimize the risk of transmitting blood-borne pathogens. Per policy, licensed staff will follow the manufacturer's guidelines and recommendations for the cleaning and disinfecting of the glucose monitor. Licensed staff will receive education on cleaning and disinfecting the glucose monitors per

the manufacturer's guidelines upon hire, and as needed. Furthermore, license staff should always wear the appropriate personal protective equipment (PPE).

A review of the Manufacturer's Instructions for the Assure Platinum Blood Glucose Monitoring System, undated, revealed to minimize the risk of transmitting bloodborne pathogens the exterior of the glucometer should be cleaned of all dirt, blood, and bodily fluids before performing the disinfection procedure, which will prevent the transmission of bloodborne pathogens. Per the instructions, the exterior of the glucometer should remain wet for the appropriate contact time according to the disinfectant's instructions.

Review of the cleaning and disinfecting instructions for Clorox Healthcare Bleach Germicidal Wipes, undated, revealed to clean and disinfect non-porous surfaces, the user would use disposable gloves and thoroughly clean the surface. Then, wrap the item with wipes, allow surfaces to remain wet for one (1) minute, and let air dry.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 42 185408 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185408 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Liberty Care and Rehabilitation Center 616 S Wallace Wilkinson Blvd Liberty, KY 42539

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Review of the facility's Competency Performing A Blood Glucose Test, revealed to properly clean and disinfect the glucometer, the nurse should wear disposable gloves. First, wipe the surface of the glucometer Level of Harm - Minimal harm or to remove any blood or body fluids. Then use a new wipe to clean the entire surface horizontally and potential for actual harm vertically, ensuring the entire surface remains wet for three (3) minutes. Finally, let the glucometer air dry.

Residents Affected - Some Review of Resident R30's electronic medical record (EMR) Face Sheet revealed the facility admitted the resident on 02/23/2019, with diagnoses to include type 2 diabetes mellitus, and long-term (current) use of anticoagulants.

Observation on 06/11/2024 at 4:17 PM, revealed RN1 was observed at the foot of Resident R30's bed holding a glucometer (blood glucose monitoring device) with a used bloody test strip in her bare hands. RN1 then exited the room and placed the contaminated glucometer on top of a towel on the medication cart, on which sat a water pitcher. She then with her bare hands, disposed of the bloody test strip in the trash container on

the medication cart. RN 1 did not perform hand hygiene after disposing of the bloody test strip.

Further observation on 06/11/2024 at 4:17 PM revealed RN1 picked up the contaminated glucometer with ungloved hands, walked back into room [ROOM NUMBER], and obtained a pair of gloves from inside the room. The SSA Surveyor could see RN1 from the hallway, and observed she wiped the glucometer, but did not allow for it to dry before putting it in a case and placing it inside the bedside drawer. She then performed hand hygiene.

During an interview, on 06/11/2024 at 4:25 PM, RN1 stated she was an agency nurse and had just performed a fingersick (a minimally invasive procedure using a lancet to draw blood from a finger) on Resident R30.

She stated she had worn gloves when she performed the fingersick. RN1 stated she should have had gloves

on when she disposed of the contaminated test strip. She stated she should not have placed the contaminated glucometer on the medication cart, as she had not yet cleaned/disinfected the glucometer when she placed it there.

In further interview with RN1, on 06/11/2024 at 4:25 PM, she stated she cleaned the glucometer and put it in its container, and stored it in the nightstand in Resident R30's room. RN1 stated residents requiring glucose monitoring had individual glucometer's. When interviewed about how she cleaned the glucometer, she showed the State Survey Agency (SSA) Surveyor a bag of Premium Adult Wet Wipes (non-germicidal personal cleaning cloths). She stated per the facility's policy, nurses should wipe the glucometer with the wipe and place it in the case. Additionally, RN1 stated she received online training, literature, and in-person instruction upon hire related to obtaining fingersticks and glucometer cleaning. She further stated she completed a competency checklist for fingersick and disinfection of the glucometer with a return demonstration during orientation.

Review of RN1's personnel file, revealed there was no documented evidence she had passed a blood glucose monitoring competency test upon hire or as part of her orientation testing on 05/23/2024.

During an interview with Licensed Practical Nurse (LPN) 3/Unit Manager, on 06/13/2024 at 3:41 PM, she stated all staff (agency and in-house) had been trained on how to perform a fingersick and how to clean and disinfect glucometer's.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 42 185408 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185408 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Liberty Care and Rehabilitation Center 616 S Wallace Wilkinson Blvd Liberty, KY 42539

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During interview with the Infection Preventionist (IP), on 06/12/2024 at 2:37 PM, she stated staff was to perform hand hygiene prior to and after a procedure and gloves should always be worn when performing a Level of Harm - Minimal harm or fingersick. Further, she stated the nurses stored glucometer's in an individual storage container in each potential for actual harm resident's room and there were no shared glucometer's. She further stated it was facility policy to clean/disinfect the glucometer before and after use with Clorox bleach wipes. The IP stated all nursing staff Residents Affected - Some should have been educated on the use of glucometer's which included obtaining a fingersick, and cleaning and disinfecting the glucometer before and after use. She stated that she and nursing leadership, the Director of Nursing (DON), and the Unit Manager, provided education and training, which required teach-back demonstration related to obtaining fingersticks and disinfecting the glucometer's. She stated this education was documented in the staff's orientation paperwork.

During an interview with the Director of Nursing (DON), on 06/14/2024 at 9:06 AM, she stated nurses should adhere to the facility's policies and guidelines related to performing point-of-care finger sticks and cleaning and disinfecting glucometer's. Additionally, she stated proper cleaning and disinfection of glucometer's per manufacturer's instructions was crucial. Further, she stated it was her expectation all staff perform hand hygiene prior to and after performing a procedure such as a fingersick.

3. Review of the CDC's Guidelines provided by the facility titled, Core Infection Prevention and Control Practices for Safe Health Care Delivery in all Settings, reviewed 11/2022, revealed reusable medical equipment should be cleaned and disinfected before use or when soiled. Further review of the guidelines revealed the personnel should be trained in the correct steps for cleaning and disinfection of shared equipment and competencies should be assessed.

Review of the facility's policy titled, Infection Control, dated 01/2024, revealed the purpose of the policy is to maintain a safe, sanitary, and comfortable environment to help prevent and manage the transmission of diseases and infection. According to the policy, department heads and managers are responsible for ensuring the implementation and adherence to infection control practices, which includes ensuring the safe cleaning and reprocessing of reusable resident care equipment. In addition, all personnel will receive training

on infection prevention and control practices (IPCP) during their hiring process and periodically thereafter.

Observation of medication pass, on 06/13/2024 at 9:00 AM, with RN1, revealed she obtained vital signs and then obtained an oxygen saturation using a pulse oxygen monitor on Resident R323. She then without sanitizing the shared blood pressure cuff and pulse oxygen monitor, obtained vital signs and oxygen saturation level for Resident R233.

In an interview with RN1, on 06/13/2024 at 9:12 AM, she stated she was to clean the blood pressure cuff and

the pulse oxygen monitor between taking vital signs for each resident with a disinfecting wipe. She further stated the dwell (time needed for the solution to remain on the device) time for the disinfection solution was three (3) minutes.

In an interview with the Staff Development/Infection Control RN, on 06/13/2024 at 9:30 AM, she stated communal equipment should be cleaned after each use. She further stated the dwell time was three (3) minutes and could be found on the disinfecting wipe package.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 42 185408 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185408 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Liberty Care and Rehabilitation Center 616 S Wallace Wilkinson Blvd Liberty, KY 42539

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 In an interview with the DON, on 06/14/2024 at 8:49 AM, she stated it was facility policy for staff to clean shared equipment after each use. Level of Harm - Minimal harm or potential for actual harm In an interview with the Administrator, on 06/14/2024 at 9:14 AM, she stated all shared equipment should be cleaned after each use. Residents Affected - Some 4a. Review of the facility's policy titled, Transmission-Based Precautions, dated 09/15/2023, revealed transmission-based precautions were initiated when a resident developed signs and symptoms of a transmissible infection or when the laboratory confirmed infection.

Review of Resident R55's electronic medical record (EMR) Face Sheet revealed the facility admitted the resident on 12/27/2023 with diagnoses including shingles, essential primary hypertension, and chronic kidney disease.

Review of Resident R55's Quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) date of 05/18/2024, revealed the facility assessed the resident as having a Brief Interview for Mental Status (BIMS) score of 13 out of 15 indicating intact cognition.

Review of Resident R55's Physician's orders dated 06/06/2024, revealed orders for contact precautions for localized shingles.

Review of Resident R55's Comprehensive Care Plan, dated 06/10/2024, revealed a focus of infection control measures and contact isolation related to shingles. The goal stated the resident's isolation will reduce the spread of the infectious agent and minimize the transmission of the infection. Interventions included: adequate PPE available for staff and visitors, practice good handwashing, and use principles of infection control and universal/standard precautions.

Observation of SRNA6, on 06/12/2024 at 9:59 AM, revealed she entered Resident R55's room without performing hand hygiene and donning PPE; although the resident's door had a sign posted stating contact precautions. SRNA5 was then observed exiting Resident R55's room without performing hand hygiene and was noted to have a remote control from Resident R55's television in her hand. She placed the television remote control on the handrail outside Resident R55's room. SRNA 6 was then observed to walk down the hallway to speak with RN1. She then came back to retrieve the remote control and noticed the contact precautions signage on R 55's door. SRNA6, then without performing hand hygiene, took a gown and gloves out of the cart and donned it prior to re-entering Resident R55's room.

Review of SRNA 6's personnel file, revealed a document titled, Agency Orientation Guide/Checklist, revealing the SRNA was trained on the topics of infection control and PPE and had signed the document on 05/02/2024.

In an interview with SRNA6, on 06/12/2024 at 10:11 AM, she was interviewed related to the signage on Resident R55's. She stated it meant she was to put on a gown and gloves before entering the resident's room. She further stated she should have performed hand hygiene and then donned a gown and gloves before entering Resident R55's room. Further, she stated she should have performed hand hygiene prior to exiting the room and should not have taken the television remote control out of the resident's room as the resident was on contact precautions. In further interview, she stated she had received education related to hand hygiene, isolation precautions, and donning PPE both by her agency and during orientation at the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 42 185408 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185408 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Liberty Care and Rehabilitation Center 616 S Wallace Wilkinson Blvd Liberty, KY 42539

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 In an interview with Licensed Practical Nurse (LPN)3/Unit Manager, on 06/13/2024 at 3:41 PM, she stated

she asked SRNA6 why she did not perform hand hygiene or don PPE prior to entering Resident R55's room, and she Level of Harm - Minimal harm or stated it was because she chose not to do so. Further, she stated she sent SRNA6 home and she would not potential for actual harm be working at the facility again. She further stated hand hygiene should be performed upon entering and prior to exiting a resident's room; and PPE should be donned prior to staff entering a room where a resident Residents Affected - Some was on contact precautions.

4b. Review of Resident R58's electronic medical record (EMR) Face Sheet revealed the facility readmitted the resident

on 05/24/2024 with diagnoses including acute systolic heart failure, dementia, chronic obstructive pulmonary disease (COPD), and benign prostatic hyperplasia (BPH).

Review of Resident R58's Admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) date of 05/06/2024, revealed the facility assessed the resident as having a BIMS' score of 12 out of 15, indicating moderate cognitive impairment.

Review of Resident R58's Physician's orders dated 05/24/2024, revealed orders for Enhanced Barrier Precautions (EBP).

Review of Resident R58's Comprehensive Care Plan, dated 05/24/2024, revealed the resident required Enhanced Barrier Precautions related to a wound. The goal stated the resident will not experience any adverse outcomes related to Enhanced Barrier Precautions. Interventions included: attempt to maintain environment cleanliness; disinfect high touch surfaces as able; encourage social interactions within the limitation of precautions; enhanced barrier protection; personal protective equipment as needed; and report to physician signs and symptoms of infection as needed.

Observation of the Scheduler/Kentucky Medicine Aide (KMA), on 06/10/2024 at 5:33 PM, revealed she failed to don PPE prior to entering Resident R58's room to deliver and set up a meal tray. She also failed to perform hand hygiene prior to exiting Resident R58's room. There was signage posted on the resident's door stating, Enhanced Barrier Precautions, and there was a PPE cart beside the door. Scheduler/KMA then returned to the food cart to remove sugar packets from a communal container and took it to resident room [ROOM NUMBER].

In an interview with the Scheduler/KMA, on 06/10/2024 at 5:42 PM, she stated facility policy was to don gown and gloves prior to entering an Enhanced Barrier Precautions room. Further, she stated staff was to sanitize hands after passing each meal tray.

5a. Observation of the Scheduler/KMA, on 06/12/2024 at 10:21 AM, revealed she was passing out snacks to residents in the 200 hallway and entered Resident R58's room. There was still signage posted on the resident's door stating, Enhanced Barrier Precautions, and there was a PPE cart beside the door. Scheduler/KMA failed to don PPE (gown and gloves) prior to entering the room to set up the resident's cereal. Additionally, she failed to perform hand hygiene prior to exiting the room. After exiting the room, she picked up another snack off the cart and delivered it to room [ROOM NUMBER].

In an interview with Licensed Practical Nurse (LPN)3/Unit Manager, on 06/13/2024 at 3:41 PM, she stated PPE should be donned prior to entering a room where a resident was in Enhanced Barrier Precautions (EBP). Further, PPE should be removed prior to exiting the contact/EBP room and hand hygiene performed.

She stated this was her expectation for all her staff.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 42 185408 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185408 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Liberty Care and Rehabilitation Center 616 S Wallace Wilkinson Blvd Liberty, KY 42539

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 In an interview with the Director of Nursing (DON), on 06/14/2024 at 8:47 AM, she stated it was her expectation staff don PPE before entering a resident's room who was in contact precautions. She further Level of Harm - Minimal harm or stated she expected staff to use hand sanitizer or wash their hands before and after providing care. potential for actual harm

In an interview with the Administrator, on 06/14/2023 at 9:12 AM, she stated it was her expectation staff don Residents Affected - Some PPE prior to entering a contact precaution room. Further, she stated staff was expected to wash their hands or use hand sanitizer prior to and after resident care. The Administrator stated staff was educated upon hire and periodically when there was an issue related to infection control. She stated house staff and agency staff both received the same training.

During interview with the Infection Preventionist (IP), on 06/12/2024 at 2:37 PM, she stated the facility followed CDC guidelines related to infection control, personal protective equipment (PPE), hand hygiene, and contact precautions. Per interview, staff was to perform hand hygiene before donning and after doffing (removing) PPE including gloves. Further, staff was to perform hand hygiene upon entering a resident's room, prior to and after completing a procedure, and prior to exiting a resident room.

5b. Observation on 06/10/2024, starting at 5:10 PM, revealed the Business Office Manager was not performing hand hygiene between passing dinner trays on the 200 hallway for resident rooms 211, 212, 213, 214, 215, and 216.

In an interview with the Business Office Manager (BOM), on 06/10/2024 at 5:51 PM, she stated when passing meal trays, staff was to sanitize hands after each tray and wash their hands after every third tray.

She further stated she should have been performing hand hygiene in between passing each supper tray.

6. Review of Resident R58's electronic medical record (EMR) Face Sheet revealed the facility admitted the resident on 5/24/2024 with diagnoses including acute systolic heart failure, dementia, chronic obstructive pulmonary disease (COPD), and benign prostatic hyperplasia (BPH).

Review of Resident R58's Admission Minimum Data Set (MDS) with an ARD date of 05/13/2024, revealed the facility assessed the resident as having a BIMS' score of 12 out of 15, indicating moderate cognitive impairment. Further review revealed the resident had an indwelling urinary catheter.

Review of Resident R58's Physician's Orders, dated 05/24/2024, revealed orders for a Foley catheter (brand name of indwelling catheter) related to benign prostatic hyperplasia with lower urinary tract symptoms.

Review of Resident R58's Comprehensive Care Plan, dated 06/11/2024, revealed a focus of indwelling catheter. The goal stated the resident will remain free from complications related to use of indwelling urinary catheter. Interventions included: observe for abdominal pain, urinary retention, and changes in urine characteristics; and catheter care as needed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 42 185408 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 185408 B. Wing 06/14/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Liberty Care and Rehabilitation Center 616 S Wallace Wilkinson Blvd Liberty, KY 42539

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Observation on 06/12/2024 at 11:42 AM, revealed SRNA5 removed a urinal with no identification from the shared bathroom and emptied Resident R58's urine form the urinary catheter drainage bag into the unlabeled urinal. Level of Harm - Minimal harm or SRNA5 touched the top and inside of the urinal with the tip of the urinary catheter drainage bag spigot. After potential for actual harm the urinary catheter drainage bag was emptied, SRNA5 stated the urinal needed to be labeled with Resident R58's name, but she did not have a sharpie marker. SRNA5 then rinsed the urinal and stored it back on the Residents Affected - Some handrail in the bathroom, but did not label or bag the urinal.

In an interview with SRNA5, on 06/12/2024 at 11:50 AM, she stated urinals were changed out when soiled and should be dated, and labeled with the resident's name. Further, she stated urinals should be stored in a bag after use. In continued interview, she stated the spigot of the urinary drainage bag should not come in contact with the urinal due to possibility of cross contamination.

In an interview with RN1, on 06/12/2024 at 2:22 PM, she stated it was common practice for staff to empty catheters into urinals. She stated urinals were to be labeled with the resident's name and date, and then rinsed after use, and placed in a plastic bag. Further, she stated it was important to not contaminate the urinary drainage bag when emptying it into the urinal.

In an interview with the DON, on 06/14/2023 at 8:51 AM, she stated urinals should be emptied and rinsed out

after each use and then stored in a bag. Further, she stated urinals should be labeled with the resident's name. Additionally, she stated urinary drainage bags were to be emptied into urinals with care taken to not contaminate the urinary drainage bag.

In an interview with the Administrator, on 06/14/2024 at 9:10 AM, she stated urinals should be labeled with

the resident's name and stored in a bag in the resident's bedside table or in the bathroom. She stated urinals were to be changed when they became soiled or had an odor.

In an interview with the IP, on 06/12/2024 at 2:37 PM, she stated nursing leadership audited staff on their daily rounds and mentored staff as well as observed competencies related to infection control while the staff was working on the floor. The IP stated the staffing agencies trained all agency nurses and the facility was responsible for checking the education of agency staff before they worked the floor. The IP stated if an agency staff was new, a seasoned staff member would work with the staff for five (5) shifts or until their competencies were validated.

In an interview with the DON, on 06/14/2023 at 8:51 AM, she stated agency and in-house staff received the same training before starting work. Furthermore, she stated she along with the Managers and the IP, provided training on contact precautions, hand hygiene, and the correct use of personal protective equipment (PPE). Following the training, nursing leadership assessed staff through a return demonstration and a post-test, requiring a score of 100%. She stated while the outside agency educated its staff related to infection control, the facility ensured compliance. She stated nurse leadership made daily rounds and did spot audits to ensure compliance with infection control; however, she stated daily rounds were not documented.

50442

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 42 185408