Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Liberty Care & Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to update care plans for three residents, resulting in incidents and injuries. One resident, known for grabbing wheelchair wheels, sustained a finger fracture due to lack of safety interventions. Another resident fell and suffered a skin tear, but his care plan was not revised to prevent future falls. A third resident continued entering other residents' rooms without care plan updates, despite staff awareness of the behavior.
Two residents with severe cognitive impairments were injured due to inadequate supervision and lack of specific interventions. One resident's hand was caught in wheelchair spokes during a transfer, resulting in an open fracture, while another resident fell and sustained a skin tear. The facility failed to update care plans with necessary interventions and did not provide documented training on specialized equipment, contributing to these incidents.
The facility failed to provide a clean and homelike environment, with observations of peeling paint, missing wood from doors, and strong urine odors in multiple resident rooms and bathrooms. Staff interviews revealed gaps in policy and practice, including the absence of a written policy for urinal storage and non-functional bathroom ventilation fans. Despite daily cleaning routines, some rooms retained a urine odor, and there was no documentation of cleaning activities for each room.
The facility failed to implement an effective infection prevention and control program, with staff not adhering to cleaning protocols for medical equipment and neglecting hand hygiene. Observations included improper handling of glucometers, failure to don PPE in precaution rooms, and inadequate management of indwelling catheters, despite existing policies and training.
A facility failed to complete a timely Level II PASARR referral for a resident with a positive Level I PASARR screening. The resident, with dementia and psychotic disturbance, was admitted without the required Level II evaluation, which should have been completed prior to admission or within 30 days. The oversight was acknowledged by the Social Services Director, who was unsure how the referral was missed, potentially leading to missed necessary services.
Two residents in the facility did not receive adequate assistance with activities of daily living (ADLs), including oral hygiene and personal grooming. One resident, dependent on staff for care, reported infrequent mouth care and inadequate bathing, confirmed by observations of poor hygiene. Another resident, also dependent, showed signs of neglect with long, dirty fingernails and unchanged clothing. Staff interviews revealed inconsistencies in care practices, highlighting a systemic failure to ensure necessary assistance with ADLs.
A resident requiring continuous oxygen therapy was observed receiving oxygen at two liters per minute per nasal cannula, but the oxygen tubing was not dated as per facility policy. Interviews with nursing staff and management confirmed that while the tubing was changed monthly, it was not consistently dated, highlighting a failure to adhere to professional standards of practice.
A resident with latent TB did not receive prescribed rifampin for three days due to a delay in delivery from the pharmacy. The medication was ordered but not delivered until four days later, resulting in missed doses. Facility staff were unaware of the delay, indicating a lapse in communication and oversight.
A resident with latent TB was prescribed two 300 mg tablets of rifampin daily but received only one tablet on two occasions. The error was identified during a medication pass observation, revealing a discrepancy in the medication count. Despite the nurse having completed medication administration training, the facility's policy for verifying medication was not followed, leading to the error.
The facility failed to label and store medications properly, as observed with two opened vials of Insulin Glargine U100 lacking an opened date on a medication cart. Staff interviews confirmed the responsibility of nursing staff to manage medication carts and ensure proper labeling and storage, following facility policy and manufacturer's guidelines.
Failure to Revise Care Plans Leads to Resident Incidents
Penalty
Summary
The facility failed to review and revise the comprehensive care plans (CCP) for three residents, leading to incidents and injuries. One resident, with a history of grabbing wheelchair wheels when resisting transport, was not provided with safety interventions in her CCP. This oversight resulted in the resident sustaining a fracture and lacerations to her finger when her hand was caught in the wheelchair spokes during transport. Despite staff awareness of this behavior, the care plan was not updated to prevent such injuries. Another resident, with a history of falls and severe cognitive impairment, fell while searching for something in his closet, resulting in a skin tear. The facility did not update his CCP with new interventions to prevent future falls, despite the incident being documented. The lack of care plan revision left the resident at risk of recurrence without additional safety measures. A third resident, who exhibited behaviors of entering other residents' rooms and removing belongings, had no updates to her CCP despite ongoing incidents. Staff interviews confirmed awareness of these behaviors, yet no new interventions were implemented to address the issue. The resident continued to enter other rooms, indicating a failure to revise the care plan to mitigate these behaviors.
Inadequate Supervision and Assistive Devices Lead to Resident Injuries
Penalty
Summary
The facility failed to ensure adequate supervision and assistive devices to prevent accidents for two residents, leading to significant injuries. One resident, with severe cognitive impairment and a history of non-compliance, was injured when her hand became entangled in the spokes of her specialized wheelchair during a transfer. Despite being aware of the resident's tendency to grab the wheels, the facility did not implement specific interventions to address this behavior, nor did they provide documented training for staff on the safe use of the specialized wheelchair. This oversight resulted in the resident sustaining an open fracture and lacerations, requiring emergency medical attention. Another resident, also with severe cognitive impairment and a history of falls, sustained a skin tear after falling while searching for something in his closet. The facility's care plan for this resident identified him as a fall risk but did not include new interventions following the fall to prevent recurrence. The lack of updated interventions in the care plan highlights a failure to adequately address the resident's fall risk and implement necessary safety measures. Interviews with staff revealed a lack of awareness and documentation regarding the specific risks and behaviors of the residents involved. The facility's policies on accidents and incidents, as well as resident rights, emphasize the importance of providing a safe environment, yet the incidents indicate a failure to adhere to these policies. The absence of documented training and specific interventions for the residents' known behaviors contributed to the accidents and subsequent injuries.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for its residents, as evidenced by observations of peeling paint, missing wood from doors, and strong urine odors in multiple resident rooms and bathrooms. Specific rooms affected included rooms 216 through 226, where the walls had peeling paint, and doors had gouges or chunks of wood missing. Additionally, shared bathrooms had open urinals containing urine that were not properly bagged or labeled, contributing to the strong odor. Interviews with facility staff revealed gaps in policy and practice regarding environmental maintenance and cleanliness. The Director of Nursing acknowledged the absence of a written policy for urinal storage after use. Housekeeping staff described their cleaning routines, which included daily cleaning of bathrooms and periodic deep cleaning of rooms. However, the Housekeeping Director admitted that some rooms and bathrooms retained a urine odor despite daily cleaning efforts, and there was no documentation of cleaning activities for each room. The Plant Operations Director noted that many bathroom ventilation fans were non-functional due to past maintenance neglect, potentially exacerbating the urine odor issue. He indicated that repairs and repainting were underway but not yet completed. Interviews with nursing staff and the Administrator confirmed expectations for urinal labeling and storage, as well as the need for nursing staff to address cleanliness issues outside of housekeeping hours. Despite these expectations, the facility's current practices and conditions did not align with the residents' right to a safe, clean, and comfortable environment.
Inadequate Infection Control Practices in LTC Facility
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by multiple observations and interviews. Staff did not adhere to proper cleaning protocols for medical equipment, such as glucometers and shared blood pressure cuffs, which were not disinfected between uses. Additionally, staff failed to perform hand hygiene before and after resident care and while passing out food, increasing the risk of infection transmission. The facility's water management plan was also inadequate, lacking a detailed flow diagram and failing to address potential Legionella growth in various parts of the building. Specific incidents highlighted include a nurse handling a contaminated glucometer without gloves and failing to disinfect it properly before storage. Another observation noted staff entering rooms of residents under contact precautions without donning appropriate PPE, despite clear signage indicating the need for such precautions. These lapses in protocol were observed even though staff had reportedly received training on infection control measures, including the use of PPE and hand hygiene. The facility's failure extended to the management of indwelling catheters, where staff did not prevent contamination during the emptying process. Urinals were not labeled or stored correctly, and the spigot of the urinary catheter drainage bag was improperly handled, risking cross-contamination. Interviews with staff revealed a lack of adherence to established protocols, despite the facility's policies and training programs designed to ensure compliance with infection control standards.
Failure to Complete Timely PASARR Level II Referral
Penalty
Summary
The facility failed to make the appropriate Level II Preadmission Screening and Resident Review (PASARR) referral for a resident who had a positive Level I PASARR screening result. The resident, identified as having dementia with psychotic disturbance and Alzheimer's disease, was admitted with a positive Level I PASARR screen indicating the need for a Level II screening. However, the facility did not ensure that the Level II screening was completed within the required timeframe, which is prior to admission or within 30 days of admission if a 30-day exemption is not obtained. The facility's policy requires that a positive Level I PASARR screen necessitates an in-depth evaluation by the state-designated authority, known as PASARR Level II. Despite this, the resident was not referred for a Level II screening until nearly a year after admission. Interviews with the Social Services Director and the Administrator revealed that the referral process was not followed as expected, and the Social Services Director was unsure how the oversight occurred. This failure to adhere to the policy potentially resulted in missed necessary services and/or medication for the resident.
Failure to Provide Adequate Assistance with ADLs
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for two residents, R55 and R58, who were unable to perform these tasks independently. R55, who was admitted with diagnoses including hypertension, depression, and muscle weakness, was assessed as dependent on staff for various ADLs, including oral hygiene and personal grooming. Despite this, R55 reported infrequent assistance with mouth care and inadequate bathing, receiving only two bed baths per week. Observations confirmed R55's complaints, noting poor hygiene and unchanged clothing over consecutive days. Similarly, R58, who was readmitted with conditions such as congestive heart failure and dementia, was also assessed as dependent for ADLs. The facility's records indicated that R58 received infrequent bed baths and no documented refusals of care. Observations revealed that R58 had long, dirty fingernails, was unshaven, and wore the same clothing over multiple days, indicating a lack of personal hygiene care. Interviews with staff, including SRNAs, LPNs, and the DON, revealed inconsistencies in the implementation of care policies. Staff members provided varying accounts of the frequency and scheduling of showers, oral care, and other ADLs, with some unaware of the specific needs or care refusals of residents R55 and R58. The facility's policies and staff interviews highlighted a systemic failure to ensure that residents received the necessary assistance with ADLs, leading to the observed deficiencies in care.
Failure to Date Oxygen Tubing for Resident Receiving Respiratory Care
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident requiring continuous oxygen therapy. The resident, who was admitted with diagnoses including congestive heart failure, dementia, benign prostatic hyperplasia, and atherosclerotic heart disease, was observed receiving oxygen at two liters per minute per nasal cannula. However, the oxygen tubing was not dated, which is inconsistent with the facility's policy that requires oxygen tubing to be changed monthly or as needed and to be dated when changed. Interviews with nursing staff, including a Registered Nurse, a Licensed Practical Nurse, the Director of Nursing, and the Administrator, revealed that the oxygen tubing was changed monthly by nursing management but was not dated as required. The Director of Nursing noted that the nursing staff often set up oxygen for new admissions without dating the tubing. This oversight was observed on two separate occasions, indicating a failure to adhere to the facility's policy and professional standards of practice for respiratory care.
Delay in Medication Delivery for Resident with Latent TB
Penalty
Summary
The facility failed to provide prescribed medications to a resident diagnosed with latent tuberculosis, as the medication rifampin was not available for administration. The physician's orders required rifampin 300 mg, two tablets, to be administered daily between 7:00 AM and 11:00 AM, starting from the date of admission. However, the medication was not delivered to the facility until four days after it was ordered, resulting in the resident missing doses on three consecutive days. Interviews with facility staff, including a registered nurse and the Director of Nursing, revealed that the pharmacy was out of the medication, leading to the delay. The staff were unaware of the delay until after the fact, indicating a lapse in communication and oversight. The facility's policy on medication administration requires medications to be prepared by authorized personnel, but the delay in obtaining the medication highlights a failure in ensuring timely access to necessary pharmaceuticals for residents.
Medication Administration Error for Resident with Latent TB
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. The resident, who was admitted with a diagnosis of latent tuberculosis, was prescribed two 300 mg tablets of rifampin to be administered daily. However, the resident received only one 300 mg tablet on two separate days. This discrepancy was discovered during a medication pass observation, where it was noted that the medication count did not align with the expected usage, indicating that the resident had not received the correct dosage. The facility's policy required medications to be administered according to the prescriber's written orders, with verification of the medication being correct at three different stages. Despite this, the error occurred, and it was revealed that the medication was delayed from the pharmacy due to a supply issue. The involved nurse had completed the necessary medication administration training and competency checks, yet the error still transpired. Interviews with the nursing staff and administration confirmed the error and the procedures in place for medication administration and error reporting.
Failure to Properly Label and Store Medications
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled, dated, and stored according to accepted professional principles, as observed in one of the four medication carts. Specifically, two opened vials of Insulin Glargine U100 on the North Wing's A-C Medication Cart were found without an opened date. This observation was made during a survey, and it was noted that the facility's policy required medications to be stored properly, following the manufacturer's or pharmacy's recommendations, to maintain their integrity and support safe drug administration. Interviews with various staff members, including an LPN, the Unit Manager, the Director of Nursing, and the Registered Pharmacist, revealed that the nursing staff was responsible for managing medication carts and ensuring proper labeling and storage. The staff acknowledged the importance of recording the date when medications were opened and disposing of expired or improperly labeled medications according to policy. The Director of Nursing and the Administrator emphasized the necessity of following guidelines to prevent medication errors and ensure resident safety.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Liberty
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Grandview Nursing And Rehabilitation Facility | 20.9 mi | ★★★★★ | 2 | 0 |
| Stanford Crossing | 21.7 mi | ★★★★★ | 17 | 2 |
| Fair Oaks Health And Rehabilitation | 22.9 mi | ★★★★★ | 0 | 0 |
| Lake Cumberland Regional Hospital Scu | 23.6 mi | ★★★★★ | 0 | 0 |
| Campbellsville Nursing And Rehabilitation Center | 24.1 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.