Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Libby Care Center during CMS and state inspections, most recent first.
Pain Not Managed Per Care Plan and Resident Preferences: A resident with a fractured elbow reported moderate to severe pain that was not relieved as expected. An LPN stated the resident received scheduled oxycodone but no additional pain med, non-pharmacological interventions, or MD contact occurred when the resident reported severe pain. The resident said staff told her she could not have more medication until later and that no other measures were provided to ease her pain.
Infection Control Lapses in Glucose Testing and Laundry Area Cleanliness: A staff member performing BG testing left a resident’s room with contaminated gloves, handled shared glucose-monitoring supplies with those gloves, and contaminated the test strip bottle with blood before cleaning it off. In the laundry room, detergent buckets sat on the floor with open hose gaps, and the washer area had lint, debris, and buildup on lids, walls, washer tops, hinges, and door seals.
A nurse left medications and a med pass liquid at the bedside for two residents without observing ingestion, despite no documented interdisciplinary assessment, physician order, or care plan for self-administration. The nurse said she assumed the residents could take their meds on their own, while the DON/designee confirmed self-administration was not set up for either resident. One resident later stated he did not know what the meds were or what they treated and said he took whatever staff brought him.
Failure to Honor Resident Choice of Attending Physician: A resident with a fractured elbow said she was assigned the facility physician instead of being offered a choice of attending MD, despite wanting her own MD who knew her meds and pain needs and with whom she felt comfortable due to prior trauma. Staff gave inconsistent accounts of physician assignment, with one stating residents were only allowed to choose MDs already affiliated with the facility or local hospital group, while the facility policy stated residents may choose their attending physician.
A resident with an ADL self-care deficit related to a failed total R knee replacement and surgical repair was not consistently given showers according to her care plan. She stated she was supposed to receive showers three times weekly, but most often only got one shower per week, and a CNA told her she could not get a shower when she requested one. Records showed fewer showers than planned despite the care plan listing bathing on Monday, Thursday, and Saturday.
Failure to prevent resident elopement: A resident who had been identified as an elopement risk exited through an alarmed door and walked several blocks away before staff located him and returned him uninjured. Staff found another resident at the exit door wearing a Wanderguard, checked outside, and did not see the missing resident until the family reported he was off-site. The resident had decreased cognition, poor safety awareness, and a history of trying to leave the facility unattended.
Surveyors identified multiple infection control failures, including improper storage of medications and supplies, unclean medication rooms and refrigerators, and overflowing sharps containers. Staff did not follow proper hand hygiene or PPE protocols during wound and IV care for a resident, and environmental cleaning was lacking, with showers and utility rooms left soiled and supplies stored on floors. Staff interviews confirmed lapses in cleaning and supply management, and residents expressed concerns about cleanliness and wound healing.
The facility did not ensure that advance directives and code status documentation were complete and consistent for three residents. In these cases, POLST forms were either unsigned by a physician, not properly filed in the EHR, or did not match the residents' stated wishes or EHR profiles. Staff acknowledged that unsigned POLSTs were entered into the electronic record before being properly authorized, contrary to policy.
Staff did not consistently document medication refrigerator temperatures as required, with records showing incomplete monitoring for the day shift and no documentation for freezer temperatures during both day and night shifts.
Staff failed to maintain a resident's dignity during peri and wound care by leaving window blinds open, resulting in the resident being exposed to the outside for an extended period. The resident expressed discomfort about being exposed, and staff later acknowledged they should have closed the blinds.
The facility failed to prevent multiple elopements and did not implement an effective system for monitoring residents at risk for elopement. Several residents left the facility unsupervised due to issues such as malfunctioning or unchecked wanderguard bracelets, lack of a comprehensive resident monitoring list, and informal procedures for elopement prevention. Staff relied on inconsistent methods to check safety devices and did not follow recommended practices for tracking and maintaining elopement prevention systems.
Staff did not adhere to a physician's order requiring a resident to wear TED hose at all times following knee surgery. Instead, staff removed the antiembolism stockings at night, referencing a facility policy, even though the facility's own policy did not direct such removal and a physician's order should have taken precedence.
A resident with a history of behavioral health issues experienced a significant mental and physical decline after hospitalization. Despite assessments and a contracted telehealth psychiatrist, the facility's interventions were ineffective, and the resident continued to display multiple disruptive behaviors. The facility documented these behaviors and issued a discharge notice, stating it was unable to manage the resident's addiction and mental health needs.
A resident admitted for rehab after knee surgery, with a history of Parkinson's, received home medications brought in by family due to insurance coverage issues. Facility staff did not verify the contents of these prescription bottles or reconcile a dosage discrepancy between the physician's order and the prescription label for clonazepam. Staff interviews revealed confusion about the process, and the facility's policy prohibiting acceptance of such medications was not followed.
A facility failed to include a resident's history and risk of suicide in the baseline care plan after admission from an overdose. Despite a suicide risk assessment and depression screening, the care plan lacked information on the resident's suicide risk or history, and there were no orders to monitor for suicide risk. Hospice notes indicated a suicide risk due to prior attempts and expressions of isolation.
The facility failed to coordinate care and communication with hospice for two residents, leading to issues with medication management and lack of documentation. Staff were unsure about hospice care plans and medication orders, resulting in inconsistencies in administration. The facility lacked documentation of hospice care plans and visit records, contributing to the deficiency in providing appropriate treatment and care.
Pain Not Managed Per Care Plan and Resident Preferences
Penalty
Summary
The facility failed to ensure that resident #57’s pain was managed according to the resident’s care plan and preferences. During an observation and interview, resident #57 was sitting in a recliner in her room and stated she had pain from a fractured elbow, rating it as 6 out of 10. She said the facility did not understand the pain management program established by her primary physician before admission, that her pain was not being managed, and that she was continuously in pain at 6 out of 10 or greater. The resident was observed grimacing and holding her arm up to her chest during the interview. Staff member E stated resident #57 reported severe elbow pain at 8 out of 10 after receiving scheduled oxycodone earlier that morning, but no additional pain medication could be given for eight hours. Staff member E stated she did not provide any non-pharmacological interventions, did not contact the physician for additional orders or treatment, and took no further action when the resident reported severe pain. Resident #57 later stated she was having pain at 10 out of 10, was told she could not have medication until mid-afternoon, and that no other treatments or care were provided to ease her pain. The care plan directed staff to attempt non-pharmacological interventions before PRN pain medication and to use timely pain medication early in recovery for acute pain. The facility policy stated residents are entitled to timely, individualized pain management in accordance with professional standards, the care plan, and personal preferences.
Infection Control Lapses in Glucose Testing and Laundry Area Cleanliness
Penalty
Summary
The facility failed to ensure proper glove use and hand hygiene during blood glucose testing for a resident on the 100-hall unit. During observation, a staff member prepared to check the resident’s blood sugar, opened the test strip bottle with gloves on, entered the resident’s room, used a lancet to obtain blood, then left the room with the same gloves still on after stating she forgot cotton balls. She returned carrying cotton balls in her gloved hands, placed them in the community glucose-monitoring supply tray, and continued the procedure. Dried blood was observed on the side of the test strip bottle, and the staff member later cleaned it off after noticing it. She stated she did not realize she had touched the cart drawers and door handle with contaminated gloves or reached into the cotton balls with a contaminated glove until interviewed. Staff stated the test strip bottle and glucose testing tray were used for all residents needing blood glucose checks on the unit. The facility also failed to keep the laundry washer area clean and free of debris. During observation, large detergent buckets were on the floor with hoses through holes in the lids and gaps around the hoses, and the lids had lint and debris on them. Lint buildup was observed on the wall above the detergent, between the washers, on top of the washers, and on the washer door hinges. The washer doors were open, and the seals had white hard water patches and dark brown congealed substance around the edges. A staff member stated the washers used detergent pulled from the floor buckets through the hoses, that caps for the lids had been requested months earlier but not received, and that lint was hard to keep under control and difficult to reach around the washers.
Failure to Assess Before Allowing Self-Administration of Medications
Penalty
Summary
The facility failed to ensure the interdisciplinary team assessed and determined that residents were safe to self-administer medications before medications were left with them. During a morning medication pass, staff member F prepared and delivered medications to resident #30, including a multivitamin, Farxiga, Glimepiride, Januvia, metformin, Risperdal, and Rybelsus, then placed the medication cup on the resident’s bedside table and left without observing the medications being taken. In a separate observation, staff member F prepared Tylenol, aspirin, Entresto, meloxicam, metoprolol, Farxiga, and a half cup of med pass liquid for resident #66, placed them on the bedside table, and left without watching the resident take them. Staff member F stated she believed the residents would be fine taking their medications on their own, but was not sure whether either resident had been evaluated or had orders for self-administration. Review of the electronic health records for residents #30 and #66 did not show an evaluation, physician order, or order for self-administration of medications. Staff member B stated the facility did not have self-administration set up for either resident and that both residents should not have been self-administering medications. During interview, resident #66 stated he did not know what the medications he received that morning were or what they were for, and said he took whatever medications were brought to him by staff. The facility policy required nursing staff to notify the physician and initiate an interdisciplinary assessment when a resident expressed interest in self-administering medications, and to document the assessment, obtain a physician order, and reflect the decision in the care plan if the resident was determined safe to self-administer.
Failure to Honor Resident Choice of Attending Physician
Penalty
Summary
The facility failed to honor a resident’s right to choose her attending physician for resident #57. During an observation and interview, the resident was sitting in a recliner in her room, watching television, and was grimacing while stating she was in pain from a fractured elbow. She said she was unhappy with the physician assigned to her when she was admitted, wanted her own physician to manage her care, and felt unsafe with the new physician because of childhood trauma and not knowing the physician. She stated her primary physician knew her medications and what would be needed to manage her pain, and that she was not given any options to choose her primary physician and was assigned the facility physician. Staff interviews showed inconsistent understanding of how attending physicians were assigned. One staff member did not know how residents were assigned a primary physician on admission. Another stated residents were not given a choice unless their primary was already affiliated with the local hospital physician group, and residents admitted outside the hospital were assigned the medical director. A third staff member stated she understood the regulation to mean residents could choose only physicians already affiliated with the facility and not outside physicians, though after rereading the regulation she understood it required offering outside physicians willing to follow the contract as a primary physician for a resident requesting those services. The facility policy stated residents may choose their attending physician and that alternatives would be discussed if a chosen physician could not meet regulatory requirements.
Failure to Honor Resident Shower Preference
Penalty
Summary
The facility failed to honor a resident’s preference for bathing three times per week for 1 of 23 sampled residents. Resident #6, who had an ADL self-care performance deficit related to a failed total right knee replacement and subsequent surgical repair, stated during interviews that she had not been getting showers as often as she wanted. She reported that her shower days were supposed to be Monday, Thursday, and Saturday, but that most of the time she only received a shower on Monday, and that when she asked a CNA for a shower on a Thursday, the CNA told her, "I can't give you one today." Staff member D stated that resident #6 wanted a shower three times a week. The resident’s care plan included bathing/shower interventions for Monday, Thursday, and Saturday day shift and PRN, but the bathing records for May and June 2026 showed that she received fewer showers than planned, including five showers in May and seven showers in June, despite 13 available shower days in each month. The facility policy stated that residents have the right to self-determination, to participate in the type, amount, frequency, and duration of care, and to make choices about aspects of life in the facility that are significant to them.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to prevent an elopement for one resident who had been identified as an elopement risk due to decreased cognition, decreased safety awareness, new admission/poor adjustment, verbalization of wanting to leave, and a history of attempts to leave the facility unattended. On 1/25/26, a door alarm sounded at an exit door on the [NAME] side of the building, and staff found another resident standing by the door wearing a Wanderguard. After that resident was redirected and the alarm was disabled, staff checked outside and did not see any other residents outside the building. Resident #3 was then noted to be missing from his room, and a search was started. During the search, the resident’s family member called the facility and reported that the resident was at a laundry mat four blocks away from the facility. The resident had exited the alarmed facility and walked away before staff located him and returned him to the facility uninjured. The resident had been assessed for elopement risk before the incident, and the record later documented that he stated he wanted fresh air, was bored, and wanted to be in the sunshine.
Widespread Infection Control Failures in Facility
Penalty
Summary
Multiple infection prevention and control deficiencies were identified throughout the facility. In the medication rooms, supplies and medications were found stacked in corners and on the floor due to inadequate shelving, and countertops were cluttered and soiled, with personal items and debris present. The medication refrigerator contained spilled wine and food, and had not been cleaned, with staff confirming that nursing was responsible for its maintenance but had not done so. Overflowing sharps containers were also observed on the floor, and various rooms, including utility and shower rooms, had uncleanable surfaces, missing or broken flooring, and visible contamination such as feces, mildew, and trash left unremoved. Staff failed to follow proper infection control practices during resident care. One staff member donned gloves before a gown and touched her hair with gloved hands, then continued to gather supplies without changing gloves, contrary to facility policy. During wound and IV care for a resident, the same staff member repeatedly failed to perform adequate hand hygiene, washing hands for less than the required 20 seconds, touching contaminated surfaces, and handling supplies and wounds without proper glove changes or handwashing. The staff member also did not properly secure PPE gowns during care, only tying them near the end of the procedure, and admitted to not following protocol because the gown was inconvenient. Environmental cleaning and supply storage were also deficient. Showers were not cleaned between resident use due to lack of available cleaning supplies, and clean linens and briefs were stored on floors and in sinks. Staff interviews revealed a lack of accountability and communication regarding cleaning responsibilities and supply management. Resident council minutes and resident interviews reflected dissatisfaction with the cleanliness and odors in shower rooms, and concerns about wound healing. Facility policies on hand hygiene and cleaning were not followed, as evidenced by direct observation and staff statements.
Inconsistent and Incomplete Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that advance directives and code status documentation were complete, accurate, and consistent with the residents' wishes and the electronic health record (EHR) for three of twenty sampled residents. In one case, a resident expressed a clear refusal of any tubes for care, including catheters and feeding tubes, yet the EHR listed the resident as full code with full treatment, and the available POLST forms were inconsistent and not properly signed by a physician. One POLST was not on file in the EHR, and no verbal physician order was documented to support the code status. For another resident, the POLST indicated a do not resuscitate status, but the required signature of the patient or decision maker was only documented as a verbal order without a follow-up physician signature. In a third case, the POLST and EHR code status did not match, and the POLST lacked a physician signature, with no verbal physician order found in the EHR. Staff interviews revealed that unsigned POLST forms were entered into the electronic record before being properly signed, contrary to facility policy and POLST instructions, which require patient or legal decision maker signatures and provider follow-up for verbal orders.
Failure to Consistently Record Medication Refrigerator Temperatures
Penalty
Summary
Staff failed to consistently record the temperatures for the medication storage refrigerator in the team one medication storage room. According to staff interviews, refrigerator temperatures were supposed to be monitored and recorded daily at the beginning of each shift. However, review of the facility's Fridge Temperature Log for June 2025 showed that temperature monitoring was only documented for the day shift 16 times over a 29-day period, and there was no documentation for either day or night shift freezer temperatures.
Failure to Maintain Resident Dignity During Peri and Wound Care
Penalty
Summary
Facility staff failed to ensure resident dignity during peri care and wound care for one resident. During the care session, two staff members performed peri and wound care with the resident's bed positioned against a window with the blinds left open. The bed was raised to the height of the windowsill, and the resident's brief was removed, exposing the resident's peri area to the uncovered window while facing the resident garden area for an extended period. The resident's buttocks were also exposed to the window during wound care. The resident verbally expressed discomfort and stated she did not want to be exposed out the window. Staff later acknowledged that the blinds should have been closed but admitted they did not think about it. Facility policy requires staff to treat each resident with dignity and respect.
Failure to Prevent Elopement and Inadequate Elopement Monitoring System
Penalty
Summary
The facility failed to prevent the elopement of three residents who were identified as being at risk for elopement and did not implement an effective elopement prevention and monitoring system for six residents at risk. Multiple incidents occurred where residents left the facility unsupervised, including one resident found wandering outside after being in the courtyard, another found across town by an off-duty staff member, and a third who exited through a window after removing the screen. In one case, a resident's wanderguard bracelet failed to trigger the alarm due to a low battery, and in another, the method of elopement was not identified. Staff interviews revealed inconsistent practices regarding the monitoring and documentation of wanderguard bracelets and elopement risk. Staff relied on residents passing by doors to check if alarms would sound, rather than using the recommended tools or tracking battery expiration dates. There was no comprehensive list of residents with wanderguard bracelets, and staff were not consistently aware of which residents required monitoring. Maintenance checked doors weekly, but there was no formal policy guiding the monitoring of residents at risk for elopement. Documentation review showed that residents with a history of exit-seeking behaviors and elopements were not always monitored according to their care plans, and the facility's procedures for wanderguard use were informal and lacked specificity. The facility's own wanderguard manual recommended tracking battery expiration dates and using checklists for monitoring, but these practices were not followed. The lack of a formal, effective system for monitoring and preventing elopement contributed to multiple incidents where residents left the facility unsupervised.
Failure to Follow Physician Orders for TED Hose Application
Penalty
Summary
Facility staff failed to follow a physician's admission order for a post-operative resident who had undergone a left total knee surgery. The physician's order specified that TED hose should be worn at all times. Upon admission, staff removed the resident's TED hose on the first night, citing a facility policy intended to prevent skin breakdown, and the stockings remained off the following morning. Interviews with staff confirmed the removal was based on facility practice, despite the physician's order, and review of the relevant facility policy did not support the removal of TED hose at night for pressure ulcer prevention.
Failure to Provide Necessary Behavioral Health Services
Penalty
Summary
The facility failed to provide necessary behavioral health services to a resident with significant behavioral needs. Upon admission, the trauma-informed care assessment did not indicate a need for interventions, and the resident had a low PHQ-9 score for depression and a high score on the Brief Interview of Mental Status. However, after a hospitalization and return to the facility, the resident experienced a noticeable mental and physical decline. Despite the facility having a contract with a telehealth psychiatrist and conducting a Significant Change MDS, the interventions suggested by the psychiatrist were not effective. The resident exhibited multiple concerning behaviors, including calling 911, being combative, offering sexual favors, attempting to remove sanitizer dispensers, possessing vape supplies and alcohol, having non-prescribed medications, exit seeking, and laying on the floor. The facility documented behavior monitoring on the Treatment Administration Record (TAR) and issued a 30-day discharge notice, citing an inability to manage the resident's addiction and mental health needs. The resident had no involved family, POA, or guardian, and the previous treatment center would not accept her back. The resident was scheduled for discharge to her son but was hospitalized and passed away before the discharge could occur. The facility did not provide behavioral health services sufficient to meet the resident's needs during this period of decline.
Failure to Verify and Reconcile Home Medications Brought by Family
Penalty
Summary
The facility failed to implement a process to verify the contents of personal prescription medication bottles brought from home before dispensing them to a resident. A resident admitted for acute rehabilitation following knee surgery, with additional diagnoses including Parkinson's disease, was provided with both new and home medications. The family supplied several of the resident's home medications due to insurance limitations, and these medications were brought in their original prescription bottles. However, there was a discrepancy between the physician's order for clonazepam (2 mg at bedtime) and the prescription label on the bottle (1 mg at night), which was not clarified by nursing staff before administration. Interviews with staff revealed inconsistent understanding and application of the facility's policy regarding the acceptance and verification of medications brought from home. Some staff were unaware of the process for medication reconciliation, and the pharmacy did not examine the pills in the bottles provided by the family. The facility's written policy stated that medications from residents or families should not be accepted due to the inability to reconcile them with prescriber orders, yet this policy was not followed in practice for this resident.
Failure to Address Suicide Risk in Resident Care Plan
Penalty
Summary
The facility failed to include a resident's history and risk of suicide in the baseline care plan for a resident who was admitted post-hospitalization from an overdose. During interviews, staff members revealed that there were no care plans or orders to monitor for suicide risk for the resident. Although a suicide risk assessment and depression screening were conducted upon admission, and it was determined that suicide was not a current issue, the resident's hospice visit notes indicated a suicide risk due to prior attempts and expressions of not wanting contact with others. The facility's care plan, initiated shortly after admission, lacked information on the resident's suicide risk or history of attempts, as well as guidance on how to identify, monitor, or support the resident if signs of risk occurred.
Failure to Coordinate Care and Communication with Hospice
Penalty
Summary
The facility failed to coordinate care and communication with hospice for two residents receiving hospice services. During interviews, staff members revealed that hospice had its own documentation and care plans, which were not shared with the facility. Hospice staff did not attend facility care conferences, and there was no designated facility staff member to coordinate with hospice. This lack of communication led to confusion among facility staff regarding medication orders and care plans for the residents. Observations and interviews highlighted issues with medication management for the residents. Staff were unsure about the hospice care plans and did not have access to hospice visit notes. Medications were provided in bottles with outdated labels, leading to inconsistencies in administration. For instance, a staff member was unsure about the correct dosage of Ativan to administer, as the medication label did not match the new physician orders. Additionally, there were multiple PRN orders for opioids without specific guidelines on when to use each dose, further complicating medication administration. The facility's records lacked documentation of hospice care plans, visit records, and standard hospice contact information until requested by surveyors. Hospice visit records indicated that one resident was considered a suicide risk, but this was not reflected in the facility's care plan. The facility was responsible for coordinating care with hospice, but there was no documentation of a designated staff member for this role. The lack of communication and documentation between the facility and hospice contributed to the deficiency in providing appropriate treatment and care according to orders and residents' preferences and goals.
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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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