Inspection Reports for
Shepherd of the Valley – Liberty
1501 TIBBETTS-WICK ROAD, GIRARD, OH, 44420
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
6.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
37% worse than Ohio average
Ohio average: 4.6 deficiencies/yearDeficiencies per year
12
9
6
3
0
Occupancy
Latest occupancy rate
156% occupied
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 1
Date: Sep 22, 2025
Visit Reason
The inspection was conducted as a complaint investigation under Complaint Number 2584291 regarding the facility's failure to maintain current CPR certification for licensed nurses.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number 2584291.
Findings
The facility administration failed to ensure an effective system to maintain current CPR certification for licensed nurses, potentially affecting all 61 residents. Several licensed practical nurses and registered nurses had expired CPR certifications that were later renewed.
Deficiencies (1)
F0835: The facility failed to administer operations effectively by not maintaining current CPR certification for licensed nurses, risking resident safety. Multiple nurses had expired CPR certifications that were renewed after the expiration dates.
Report Facts
Residents affected: 61
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 8
Date: Sep 22, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to notify a resident's Power of Attorney of a change in condition, inadequate assistance with activities of daily living, insufficient post-fall investigations, failure to provide appropriate care for urinary tract infections, medication errors, improper food safety practices, lapses in CPR certification, and failure to follow infection control precautions.
Complaint Details
The complaint investigation focused on allegations of failure to notify Resident #28's POA of condition changes, inadequate assistance with activities of daily living, incomplete post-fall investigations, failure to properly assess and treat UTIs, medication errors, food safety violations, lapses in CPR certification, and failure to follow infection control precautions. The facility was found non-compliant in all these areas.
Findings
The facility was found to have multiple deficiencies including failure to notify Resident #28's POA of condition changes and treatment, inadequate assistance with hygiene for Resident #3, incomplete post-fall investigations for Resident #34, failure to properly assess and treat Resident #28's UTI, medication administration errors affecting Residents #11 and #69, improper food storage and handling, lapses in CPR certification among nursing staff, and failure to follow transmission-based infection control precautions for Residents #57 and #71.
Deficiencies (8)
F 0580: The facility failed to notify Resident #28's Power of Attorney of changes in condition and treatment related to a urinary tract infection.
F 0677: The facility failed to provide adequate assistance with activities of daily living, resulting in poor hygiene and odor for Resident #3.
F 0689: The facility failed to conduct thorough post-fall investigations and implement appropriate interventions for Resident #34 after multiple falls.
F 0690: The facility failed to provide appropriate care and timely assessment for Resident #28's urinary tract infection, including delayed urine specimen collection and lack of physician notification.
F 0759: The facility failed to maintain a medication error rate below five percent, with two medication errors observed during administration to Residents #11 and #69.
F 0812: The facility failed to ensure food was stored, prepared, and served in accordance with professional food safety standards, including undated and improperly stored food items and presence of cleaning chemicals near food preparation areas.
F 0835: The facility failed to maintain current CPR certification for licensed nurses, with multiple lapses identified in certification status.
F 0880: The facility failed to ensure transmission-based infection control precautions were followed, with staff and visitors not wearing required personal protective equipment when caring for Residents #57 and #71 on Contact and Droplet Isolation.
Report Facts
Facility census: 61
Medication error rate: 8
Urine culture colony forming units: 100000
Number of medication administration opportunities: 25
Number of medication errors: 2
Number of residents affected by deficiencies: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physician #735 | Physician | Ordered urinalysis and urine culture for Resident #28; involved in delayed treatment |
| POA #736 | Power of Attorney for Resident #28 | Not notified by facility of Resident #28's condition changes and treatment |
| LPN #684 | Licensed Practical Nurse | Observed Resident #3's poor hygiene and odor |
| CNA #740 | Certified Nursing Assistant | Observed and reported Resident #3's fingernail condition and odor |
| RRN #719 | Restorative Registered Nurse | Confirmed Resident #3's fingernail condition and odor |
| LPN #685 | Licensed Practical Nurse | Interviewed regarding Resident #34's fall risk and care |
| RN #715 | Registered Nurse | Observed medication administration errors |
| LPN #685 | Licensed Practical Nurse | Observed medication administration errors |
| CDD #656 | Chef Dietary Director | Verified food safety violations in kitchen |
| HRD #742 | Human Resources Director | Verified CPR certification lapses among nursing staff |
| DON | Director of Nursing | Interviewed regarding notification failures, CPR certification, and infection control |
| COTA #731 | Certified Occupational Therapy Assistant | Failed to wear PPE while providing care to Resident #57 on Contact Isolation |
| CNA #732 | Certified Nursing Assistant | Failed to wear PPE while providing care to Resident #57 on Contact Isolation |
| LPN #741 | Licensed Practical Nurse | Failed to wear PPE while providing care to Resident #71 on Droplet Isolation |
| CNA #630 | Certified Nursing Assistant | Failed to wear PPE while providing care to Resident #71 on Droplet Isolation |
| ADON/IP #627 | Assistant Director of Nursing/Infection Preventionist | Confirmed infection control PPE lapses and policies |
Inspection Report
Complaint Investigation
Census: 65
Deficiencies: 1
Date: May 7, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to maintain a clean environment, including mechanical lifts.
Complaint Details
This deficiency represents non-compliance investigated under Complaint Number OH00163463.
Findings
The facility failed to maintain cleanliness in resident rooms and common areas, including visible dirt and dust buildup on floors, toilets, walls, baseboards, fireplaces, tables, and mechanical lifts. Housekeeping services were subcontracted and not consistently cleaning daily as expected.
Deficiencies (1)
F 0921: The facility failed to maintain a clean environment, including mechanical lifts, with visible dirt and dust buildup in resident rooms and common areas. This affected Resident #3 and had the potential to affect all 65 residents.
Report Facts
Residents affected: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing (ADON) #112 | Verified observations of cleanliness issues | |
| Environmental Services Supervisor (ESS) #165 | Provided information on housekeeping schedules and audits | |
| Serve Pro Manager (SPM) #161 | Provided information on housekeeping staffing and responsibilities | |
| Housekeeper (HK) #162 | Provided information on cleaning frequency and practices |
Inspection Report
Routine
Census: 60
Deficiencies: 6
Date: Oct 5, 2023
Visit Reason
Routine inspection of Shepherd of the Valley Liberty nursing home to assess compliance with regulatory requirements including resident care, abuse prevention, care planning, fall prevention, and respiratory care.
Findings
The facility was found deficient in multiple areas including failure to feed residents in a dignified manner, failure to prevent misappropriation of resident property, incomplete care plans for several residents, failure to prevent a fall with injury, and failure to administer oxygen as ordered.
Deficiencies (6)
F 0550: The facility failed to ensure residents were fed in a dignified manner as staff were observed feeding residents while standing instead of seated.
F 0602: The facility failed to protect Resident #43 from misappropriation of property when a staff member used the resident's debit card without consent.
F 0607: The facility failed to implement abuse prevention policies effectively to prevent staff misappropriation of Resident #43's property.
F 0656: The facility failed to develop comprehensive care plans for Residents #15, #56, #60, and #67, omitting key needs such as oxygen use, anticoagulant therapy, tracheostomy care, and dialysis.
F 0689: The facility failed to prevent a fall with injury for Resident #20 due to lack of fall prevention interventions like a fall mat and bed in the lowest position.
F 0695: The facility failed to administer oxygen to Resident #15 as ordered, with oxygen initially set at one liter instead of the prescribed three liters.
Report Facts
Residents affected: 6
Facility census: 60
Residents reviewed for misappropriation: 21
Residents reviewed for care plans: 20
Residents reviewed for falls: 3
Residents reviewed for respiratory care: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Hospitality Aide #700 | Hospitality Aide | Named in misappropriation of Resident #43's debit card |
| Director of Nursing | Director of Nursing | Confirmed video evidence of misappropriation and fall investigation details |
| Licensed Practical Nurse #520 | Licensed Practical Nurse | Observed feeding residents standing and confirmed care plan omissions |
| Registered Nurse #506 | Registered Nurse | Confirmed lack of care plan for Resident #60's tracheostomy |
| Corporate Registered Nurse #706 | Registered Nurse | Confirmed lack of care plan for Resident #67's dialysis |
| Licensed Practical Nurse #515 | Licensed Practical Nurse | Interviewed regarding fall incident for Resident #20 |
| Licensed Practical Nurse #513 | Licensed Practical Nurse | Adjusted oxygen setting for Resident #15 to correct order |
Inspection Report
Routine
Census: 55
Deficiencies: 3
Date: Jul 29, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including notification procedures for resident transfers or discharges, Quality Assurance and Performance Improvement (QAPI) committee meetings, and COVID-19 testing protocols for staff.
Findings
The facility failed to notify the Ombudsman in writing of resident transfers or discharges to the hospital affecting four residents. The QAPI committee did not meet quarterly as required and lacked Medical Director attendance. The facility also failed to ensure COVID-19 testing or vaccination status verification for agency staff, potentially affecting all 55 residents.
Deficiencies (3)
F 0623: The facility failed to provide timely notification to the Ombudsman of resident transfers or discharges to the hospital for four residents. Documentation and staff interviews confirmed no notification was sent.
F 0868: The facility failed to ensure the QAPI committee met quarterly and did not have the Medical Director in attendance. Meeting records showed only two meetings in the past year with incomplete attendance.
F 0886: The facility failed to ensure agency staff were tested for COVID-19 or had verified vaccination status. Interviews and records showed no testing documentation for unvaccinated agency staff, affecting two employees and potentially all residents.
Report Facts
Facility census: 55
Number of residents affected by notification deficiency: 4
QAPI meetings held: 2
Agency employees reviewed: 3
Agency employees affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Admissions/Marketing coordinator #310 | Admissions/Marketing coordinator | Interviewed regarding transfer notifications to Ombudsman |
| Licensed Practical Nurse #605 | Licensed Practical Nurse | Authored nursing notes related to Resident #1's hospital transfer |
| Primary Care Physician #606 | Primary Care Physician | Notified and ordered hospital transfer for Resident #1 |
| Registered Nurse #607 | Registered Nurse | Authored nursing notes related to Resident #1's hospital admission |
| Director of Clinical Services #900 | Director of Clinical Services | Interviewed regarding QAPI meetings and Medical Director attendance |
| Registered Nurse #604 | Registered Nurse | Interviewed regarding COVID-19 testing and agency staff vaccination status |
| RN/Infection Control #603 | RN/Infection Control | Interviewed regarding COVID-19 testing protocols |
| Agency STNA #600 | Agency State Tested Nursing Assistant | Interviewed regarding vaccination and testing status |
| Agency STNA #601 | Agency State Tested Nursing Assistant | Interviewed regarding vaccination and testing status |
| Agency STNA #602 | Agency State Tested Nursing Assistant | Interviewed regarding vaccination status |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding COVID-19 testing documentation for agency staff |
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