WEST LIBERTY NURSING AND REHABILITATION CENTER

Nursing Home Inspector

774 LIBERTY ROAD
WEST LIBERTY, KY 41472
Morgan County
Phone: 606-743-3846
Provider Number: 185274
Last Inspection: 09/24/2016

About the Nursing Home

Number of Beds: 48
Number of Residents: 41
Beds Available: 7
Percent Occupancy: 85%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Both
Ownership: For profit - Corporation
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

76

Facility
76

County
12

KY
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

76

2016
22

2015
8

2014

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

9/24/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 10/29/2016
 
Failed To: Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. Isolated : Minimal 3 10/17/2016
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Isolated : Minimal 3 10/17/2016
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Immediate 5 10/17/2016
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Pattern : Minimal 4 10/29/2016
 
Failed To: Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. Isolated : Minimal 3 10/17/2016
 
Failed To: Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. Isolated : Minimal 3 10/17/2016
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Actual 4 10/17/2016
 
Failed To: Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. Isolated : Minimal 3 10/29/2016
 
Failed To: Have enough nurses to care for every resident in a way that maximizes the resident's well being. Isolated : Immediate 5 10/17/2016
 
Failed To: Store, cook, and serve food in a safe and clean way. Pattern : Minimal 4 10/17/2016
 
Failed To: Make sure that all required doctor visits are made personally. Pattern : Minimal 4 10/17/2016
 
Failed To: Provide routine and 24-hour emergency dental care for each resident. Pattern : Minimal 4 10/17/2016
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Immediate 5 10/17/2016
 
Failed To: Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident . Isolated : Immediate 5 12/6/2016
 
Failed To: Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility Isolated : Immediate 5 10/29/2016
 
Failed To: Give or get quality laboratory services/tests in a timely manner to meet the needs of residents. Isolated : Immediate 5 10/17/2016
 
Failed To: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Isolated : Immediate 5 12/6/2016
 
Failed To: 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. Isolated : Minimal 3 10/17/2016
 

8/20/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Offer other nutritional food to each resident who will not eat the food served. Pattern : Minimal 4 9/11/2015
 
Failed To: Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility Isolated : Minimal 3 9/11/2015
 
Failed To: Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. Isolated : Minimal 3 9/11/2015
 
Failed To: Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. Isolated : Minimal 3 9/11/2015
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Isolated : Minimal 3 9/11/2015
 
Failed To: Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. Isolated : Minimal 3 9/11/2015
 
Failed To: Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. Isolated : Minimal 3 9/11/2015
 

9/25/2014 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Pattern : Minimal 4 11/1/2014
 
Failed To: Put firmly secured handrails on each side of hallways. Pattern : Minimal 4 11/1/2014
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

12/1/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. Isolated : Minimal 3 12/6/2016
 
Failed To: Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident . Isolated : Minimal 3 12/6/2016
 
Failed To: Set up an ongoing quality assessment and assurance group to review quality deficiencies quarterly, and develop corrective plans of action. Isolated : Minimal 3 12/6/2016
 

8/25/2016 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Isolated : Minimal 3 9/27/2016
 
Failed To: Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Isolated : Minimal 3 9/27/2016
 
Failed To: Allow residents the right to participate in the planning or revision of care and treatment. Isolated : Actual 4 9/27/2016
 
Failed To: Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. Isolated : Minimal 3 9/27/2016
 
Failed To: Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. Isolated : Actual 4 9/27/2016
 

9/8/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Tell the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave. Isolated : Minimal 3 9/11/2015
 

7/30/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Isolated : Minimal 3 9/11/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg KY State Avg
Number of Residents 41 41.00 79.68
Registered Nurses 0.63 0.63 0.86
Licensed Practical / Vocational Nurses 0.43 0.43 0.87
Certified Nursing Assistants 3.01 3.01 2.40
Total Staff Hours 4.07 4.07 4.13

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% KY State Avg%
of high risk long-stay residents with pressure ulcers 3 3 5
of long-stay residents assessed and appropriately given the pneumococcal vaccine 100 100 95
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 98 98 95
of long-stay residents experiencing one or more falls with major injury 6 6 3
of long-stay residents who have depressive symptoms 14 14 2
of long-stay residents who lose too much weight 6 6 7
of long-stay residents who received an antianxiety or hypnotic medication 40 40 31
of long-stay residents who received an antipsychotic medication 11 11 19
of long-stay residents who self-report moderate to severe pain 1 1 6
of long-stay residents who were physically restrained 1 1 0
of long-stay residents whose ability to move independently worsened 18 18 21
of long-stay residents whose need for help with daily activities has increased 9 9 16
of long-stay residents with a catheter inserted and left in their bladder 2 2 2
of long-stay residents with a urinary tract infection 3 3 4
of low risk long-stay residents who lose control of their bowels or bladder 25 25 49
of short-stay residents assessed and appropriately given the pneumococcal vaccine 87 87 84
of short-stay residents who had an outpatient emergency department visit 14 14 14
of short-stay residents who newly received an antipsychotic medication 7 Not Available   59
of short-stay residents who self-report moderate to severe pain 0 7 2
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 83 0 16
of short-stay residents who were rehospitalized after a nursing home admission 19 83 83
of short-stay residents with pressure ulcers that are new or worsened 2 19 22