West Liberty Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at West Liberty Nursing and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF656Jan 25, 2023

  Based on observation, interview, record review, and facility policy review, it was determined the facility failed to ensure the comprehensive person-centered care plan was developed and implemented with interventions necessary for monitoring a resident with behaviors of wandering, who was at risk for elopement for one (1) of five (5) residents (Resident #20). The facility admitted Resident #20 with a history of wandering and elopement at home. The facility assessed Resident #20 to have wandering behaviors and care planned the resident as an elopement risk due to disorientation to place and impaired safety awareness. […]

• Immediate jeopardy, isolatedF689Jan 25, 2023

  Based on observation, interview, record review, facility document and policy review, it was determined, the facility failed to ensure adequate and necessary supervision was provided for one (1) of five (5) sampled residents reviewed for elopement (Resident #20). Resident #20 eloped from the facility on 01/04/2023, without staff's knowledge and was found approximately 1.6 miles from the facility. Even though the facility's door alarmed when Resident #20 exited, facility staff failed to investigate and determine why the door alarm was sounding or initiate a search outside to ensure no residents had exited the facility without staff's knowledge. […]

• No harm, potential for more than minimal, isolatedF732Aug 26, 2025

  Based on observation, interview and record review, the facility failed to post the nurse staffing data daily at the beginning of each shift.The findings include:Observation on 08/24/2025 at 11:30 AM, revealed a posted daily staffing sheet dated 08/21/2025. The facility had not updated its posted staffing sheet for three days. The facility must post the following information daily: facility name, the current date, the total number, and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift:1. Registered nurses.2. Licensed practical nurses or licensed vocational nurses (as defined under State law).3. Certified nurse aides.4. […]

• No harm, potential for more than minimal, isolatedF761Aug 26, 2025

  Number of residents sampled: Number of residents cited: Based on observations, interviews, and policy review, the facility failed to ensure proper storage of all medications. The findings include:Review of the undated policy titled Medication Storage revealed it is the policy of the facility to ensure all medications housed on the premises will be stored in the pharmacy and/or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation, and security.Observation on 08/24/2025 at 12:04 PM, 25 loose pills were retrieved by SSA from the bottom of the medication drawers of cart one (1), and 11 loose pills were retrieved from the medication drawers of cart two (2). […]

• No harm, potential for more than minimal, isolatedF803Aug 26, 2025

  Number of residents sampled: Number of residents cited: Based on observation, interview, record review, and review of the facility's policy, the facility failed to ensure the menu was followed as written.Findings include: Review of the facility's policy titled, Food: Quality and Palatability dated 02/2023, revealed Food would be prepared by methods that conserve nutritive value, flavor and appearance. Food would be palatable, attractive and served at a safe and appetizing temperature. Continued review revealed food palatability refers to the taste and/or flavor of the food. Further review revealed Menu items were to be prepared according to the menu, production guidelines, and standardized recipes. Cooks were to use proper cooking techniques to ensure color and flavor retention. […]