Average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Shepherd Of The Valley Liberty during CMS and state inspections, most recent first.
During a multi-day power outage, the facility relied only on a gas stove, leaving kitchen equipment such as the food processor unusable and resulting in residents on pureed diets receiving limited items like mashed potatoes, stuffing, tomato soup, and cream of wheat without clear protein sources. Several residents with dysphagia, protein-calorie malnutrition, significant weight loss, COPD, and other chronic conditions had orders for pureed diets and nutritional supplements, but documentation in progress notes, intake records, and MARs did not show that any additional supplementation beyond routine orders was provided during the outage. Dietary staff could not specify what protein foods were served, no records were kept of the actual foods provided, tray tickets did not list what was served, and one resident reported not getting enough to eat or receiving extra items such as shakes or ice cream. The DON and RD could not verify that residents on pureed diets received well-balanced, protein-adequate meals during this emergency period.
The facility did not maintain an effective system to ensure that all licensed nurses, including LPNs and RNs, held current CPR certification as required by policy. Multiple staff members were found to have worked with expired CPR certifications, a lapse confirmed by both the Human Resources Director and the DON. This deficiency had the potential to affect all residents in the facility.
Failure to notify POA of resident’s UTI change in condition. A cognitively intact resident with CVA-related hemiplegia and bladder incontinence had urine testing ordered after a change in condition, then a positive culture and antibiotic orders were documented. The resident’s daughter, who was also the POA, stated she was not informed of the suspected UTI, confirmed UTI, or treatment, and the DON verified there was no documented evidence of notification.
Failure to Maintain Resident Hygiene: A cognitively intact resident with MS, quadriplegia, and severe extremity impairment was dependent for ADLs including bathing and personal hygiene, but staff did not maintain proper hand hygiene. Surveyors observed a strong unpleasant odor in the room, clenched hands, and fingernails that were long, yellow, and dirty with brown material underneath; CNAs confirmed the resident’s hands were not being kept properly clean.
Incomplete Post-Fall Investigations and Missing Care Plan Updates: A resident with dementia, ataxic gait, Meniere's disease, and a high fall risk had repeated falls, including incidents from a recliner and a later fall with a head goose egg. The record showed inconsistent fall times, missing vital sign documentation in one investigation, no documented investigation for one fall, and no care plan notation or individualized intervention updates after the later falls. The DON stated a fall risk assessment did not need to be completed after every fall, and fall packet documentation was not included in the chart.
Delayed UTI Assessment and Specimen Collection
Surveyors found that the facility did not maintain a clean environment, with a resident's room and bathroom showing visible dirt, dust, and dried feces, and mechanical lifts in common areas having significant dirt and debris. Interviews and documentation revealed inconsistent cleaning schedules and a lack of clear protocols for cleaning certain areas, despite the facility's stated goal of daily thorough cleaning.
Failure to Ensure Adequate Pureed Diet Nutrition During Power Outage
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents received a nourishing, palatable, well‑balanced diet that met daily nutritional and special dietary needs during a prolonged power outage. The facility experienced a power outage from the evening of 03/13/26 until the morning of 03/15/26, during which only the gas stove functioned in the kitchen because there were no generator-connected (red) outlets. As a result, staff could not use the food processor to prepare pureed foods and instead served items that could be made with boiling water. Dietary staff reported that residents on pureed diets were given mashed potatoes, stuffing, tomato soup, and cream of wheat, and no record was kept of the specific foods served during this period. Tray tickets for affected meals did not indicate what foods were actually provided. Four residents with orders for pureed diet textures were specifically reviewed. One resident had dementia, type 2 diabetes mellitus, dysphagia oral phase, and was care planned as at risk for nutritional decline, with interventions including pureed diet with thickened liquids and house supplements twice daily. Another resident had protein calorie malnutrition, muscle wasting and atrophy, diverticulosis, and a history of significant weight loss, and was also care planned for pureed texture and house supplements twice daily. A third resident had dysphagia oropharyngeal phase, respiratory failure, intellectual disabilities, adult failure to thrive, and was ordered a pureed diet with nectar thick liquids and a daily house supplement. The fourth resident had COPD, GERD, mild cognitive impairment, major depressive disorder, significant weight loss, and was ordered a pureed diet with nectar thick liquids, Magic Cup with meals, and house supplements with meals for weight loss. For all four residents, review of progress notes, nurse aide intake tracking, and MARs showed no documentation that any additional supplementation beyond the routinely scheduled supplements was provided during the power outage dates. Dietary staff, including the Dietary Supervisor and Dietary Director, were unable to identify what protein sources were served to residents on pureed diets during this time. A DTR and a Regional RN asserted that residents on pureed diets received nutritional supplements and that items such as tomato soup provided some protein, but the RD could not confirm whether additional supplementation was actually provided during the outage. One cognitively intact resident reported not getting enough to eat during the outage and stated that, although some food was provided, it was not enough to satisfy hunger and no additional items like ice cream or health shakes were offered. The DON confirmed that tray tickets did not specify what foods were served during the power outage, and there was no documentation to substantiate that residents on pureed diets received balanced meals or adequate protein during this emergency period. The deficiency affected four reviewed residents with pureed diet orders and had the potential to affect all eight residents in the facility who required pureed diet textures. The lack of a system to ensure well‑balanced, nutritionally adequate pureed meals during the power outage, combined with the absence of documentation of what foods and supplements were actually provided, led to the finding that the facility did not meet the requirement to provide each resident with a diet that met daily nutritional and special dietary needs during the emergency event.
Failure to Ensure Current CPR Certification for Nursing Staff
Penalty
Summary
Facility administration failed to maintain an effective system to ensure that all licensed nurses held current cardiopulmonary resuscitation (CPR) certification, as required by facility policy. Review of personnel files revealed multiple instances where CPR certifications for both LPNs and RNs had expired before being renewed. The Human Resources Director confirmed that lapses in CPR recertification were identified through the facility's tracking process. The Director of Nursing stated that corporate was responsible for CPR certification and was unaware that some nurses were not current with their certifications. The DON also confirmed that staff performing CPR were required to maintain current certification, and that CPR recertification was offered through the American Heart Association. Facility policy required all direct care staff to maintain current CPR certification as a condition of employment, with failure to obtain certification within 30 days of expiration resulting in removal from the work schedule and possible disciplinary action. Despite this policy, several nurses were found to have worked with expired CPR certifications, potentially affecting all 61 residents in the facility. The deficiency was identified during a complaint investigation and verified through interviews and record review.
Failure to Notify POA of Resident’s UTI Change in Condition
Penalty
Summary
The facility did not ensure Resident #28’s POA was notified of a change in condition related to a suspected and later confirmed urinary tract infection. Resident #28 was admitted with diagnoses including cerebral infarction, left-sided hemiplegia, and congestive heart failure, and was documented as cognitively intact on the annual MDS. The care plan noted bowel and bladder incontinence, weakness, fatigue, and a need for assistance with toileting and peri care. Physician orders were entered for urinalysis and urine culture and sensitivity after concerns arose, and later a straight catheter specimen was obtained with dark yellow urine collected for testing. The urine culture later showed greater than 100,000 CFU/mL of Providencia stuartii, and new orders were entered for cefpodoxime for UTI. Review of the progress notes showed no documented evidence that the resident’s daughter, who was also the POA, was notified of the new orders, the urine testing, the positive culture result, or the antibiotic treatment. During interview, the POA stated she was not called and was upset that she had not been informed of the resident’s potential UTI or confirmed UTI. The resident also stated she was now receiving antibiotics and had experienced pain with urination before starting them, and the DON verified there was no documented evidence that the daughter had been notified of the change in condition, urinalysis results, or treatment.
Failure to Maintain Resident Hygiene
Penalty
Summary
The facility failed to ensure staff provided assistance to maintain good hygiene for a resident with multiple sclerosis, acute respiratory failure with hypoxia, quadriplegia, contracture of joint, and flaccid neuropathic bladder. The resident’s quarterly MDS showed he was cognitively intact, had impairment of both upper and lower extremities, and was dependent for ADLs including showering/bathing, personal hygiene, and bed mobility. His care plan identified a need for assistance with ADLs related to multiple sclerosis, but it did not list specific interventions for showering/bathing or hygiene. During observation, the resident was found lying in bed with both hands clenched tightly into his palms and his legs contracted toward his chest, and there was a pervasive sweet, unpleasant odor in the room. Staff later prepared to give him a bed bath because an odor was noted. On closer observation, his fingernails were approximately a half inch long, yellow in color, and had brown material underneath each nail. A CNA confirmed the nails were long and dirty, and while washing his hands, a moderate amount of yellow material was noted on the washcloth. Staff also confirmed the resident’s hands were not being kept properly clean and that an odor was present.
Incomplete Post-Fall Investigations and Missing Care Plan Updates
Penalty
Summary
The facility failed to complete thorough post-fall investigations for a resident with multiple fall risk factors, including ataxic gait, dementia, macular degeneration, Meniere's disease, severe cognitive impairment, bilateral upper extremity impairment, and a history of a recent fall. Resident #34 was identified as high risk for falls on the fall risk evaluation, and the care plan documented a fall on 07/20/25 with interventions related to monitoring, physician notification, and therapy consultation. After a fall on 08/21/25, the resident was found on the floor in front of her recliner and stated she had pushed the wrong button on the chair, causing it to change position and slide her to the floor. The investigation noted no witnesses and stated neurological checks, ROM, and vital signs were within normal limits, but no vital signs were documented in the investigation. Although the investigation indicated the care plan was reviewed and updated, the record did not show a new individualized fall intervention in the resident's chart for the later fall on 08/28/25, when she was again found on the floor with a 3.0 cm by 2.5 cm goose egg on her head and was sent to the ED for evaluation. A subsequent witnessed fall on 09/12/25 was documented in the incident log and progress note as occurring at 3:30 P.M., but the interdisciplinary fall investigation listed the fall time as 5:45 P.M. The investigation included general statements about safety measures, frequent checks, and one-to-one interventions, and stated the care plan was reviewed and updated. Review of the care plan showed no notation of the 08/21/25, 08/28/25, or 09/12/25 falls and no updates to interventions after 07/23/25 to prevent subsequent falls. The DON stated a fall risk assessment was not and did not need to be completed after every fall, and that a fall paper packet was completed after a fall but was not part of the medical record.
Delayed Urine Specimen Collection and UTI Assessment
Penalty
Summary
The facility failed to ensure appropriate care and services were provided to assess for and treat a urinary tract infection for Resident #28, who was cognitively intact, dependent for toileting hygiene, required partial to moderate assistance with personal hygiene, and was frequently incontinent of urine. The resident’s care plan identified bowel and bladder incontinence, weakness, fatigue, and the need for assistance with toileting and peri care, and included monitoring for signs of urinary infection and reporting concerns to the nurse and physician. On 08/27/25, Physician #735 ordered a urinalysis and urine culture and sensitivity for Resident #28. On 08/29/25, staff documented two attempts to obtain urine by straight catheter, but white sludge clogged the catheter both times, and there was no evidence the physician was notified of the failed attempts. The record also did not show evidence of attempts to collect the urine or notification to the physician from 08/29/25 through 09/03/25 regarding the inability to obtain the specimen as ordered. On 09/03/25, a new order was entered for urine testing every shift until obtained. On 09/04/25, staff documented that the specimen was unable to be obtained that shift, with no evidence the physician was notified or that a reason was documented. Later that day, urine was obtained by straight catheter and the lab ultimately reported greater than 100,000 CFU/mL of Providencia stuartii. The final report was sent to the physician on 09/09/25, and new antibiotic orders were entered on 09/10/25. Resident #28 stated she had pain with urination before starting antibiotics, and the NP and physician both stated the delay in obtaining the specimen should not have occurred.
Failure to Maintain Clean Environment and Equipment
Penalty
Summary
The facility failed to maintain a clean environment, including resident rooms and mechanical lifts, as observed during an initial tour with the Assistant Director of Nursing. In one resident's room, the floor was dirty with visible crumbs and dust buildup, the toilet had yellow and brown streaks on the outer bowl, and there was a brown spot on the wall that appeared to be dried feces. Additional observations included dust buildup on baseboards, fireplaces, and tables in common areas, as well as visible dirt and debris on mechanical lifts such as sit-to-stand and Hoyer lifts. These findings were verified by facility staff at the time of observation. Interviews with the Environmental Services Supervisor and housekeeping staff revealed inconsistencies in cleaning schedules, with some rooms cleaned every three days and others daily or every other day. Housekeeping services were subcontracted, and there was a lack of a set schedule for cleaning certain areas such as baseboards and fireplaces. Documentation review showed that the facility's stated goal was daily thorough cleaning, but audit tools and workflow sheets indicated cleaning was performed as needed or when visible dirt was present. Photos provided by the cleaning contractor confirmed the presence of unclean conditions in the resident's bathroom, and meeting minutes reflected ongoing issues with housekeeping services.
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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 Girard
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Liberty Health Care Center Inc | 2.3 mi | ★★★★★ | 9 | 0 |
| Autumn Hills Care Center | 2.6 mi | ★★★★★ | 2 | 0 |
| Heritage Manor Jewish Hm For | 3.6 mi | ★★★★★ | 2 | 0 |
| Windsor Health Care Center | 4.3 mi | ★★★★★ | 1 | 0 |
| Omni Manor Nursing Home | 4.9 mi | ★★★★★ | 1 | 0 |
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