Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Valley Oaks Care Center during CMS and state inspections, most recent first.
Food storage and sanitation practices were not maintained in the dietary area. Staff observed undated and unsealed food items in the freezer, dry storage, and prep area, including unlabeled bags with an unknown brown substance, open containers of spices, and a dented can of sliced apples kept for use. The grill had grease residue, the freezer floor had spilled sherbet, the cooler floor had peeling paint, and the ice machine had dark residue inside. A Dietary Aide did not recall seeing the cleaning schedule, and facility checklists required food items to be labeled, sealed, wrapped, and dated, with surfaces and equipment cleaned regularly.
A facility failed to maintain comfortable sink water temperatures in multiple resident rooms. Several residents reported or were observed with cold water that stayed cold even after running for several minutes, and a CNA confirmed the issue in some rooms. The MS said a bad circulation tank had been identified and that he did not consider the sink water a problem because residents used the shower room, while also stating he did weekly checks but did not document which rooms were tested or any follow-up maintenance.
Two residents had inaccurate MDS assessments. One resident’s MDS incorrectly stated antipsychotics had not been received despite an active Risperdal order for paranoia and agitation. Another resident’s MDS misreported pressure ulcer status and did not fully capture insulin use, even though the record showed Stage II pressure ulcers and sliding-scale Humalog coverage on two days; an RN confirmed the errors.
Failure to provide ordered oxygen and keep respiratory documentation accurate. A resident with multiple serious diagnoses, including TBI, dysphagia, and heart failure, had a physician order for continuous O2 via NC, but surveyors observed him repeatedly without oxygen while the concentrator was not in use and out of reach. The chart also contained inaccurate respiratory documentation, including entries showing oxygen by ventilator or trach when the resident had neither, and the MD, RN, and DON gave conflicting accounts about the oxygen order and whether it was actually being provided.
Inaccurate documentation was found in a resident’s chart involving oxygen therapy and pulse oximetry. The care plan and physician order called for continuous O2 via NC, but the TAR showed oxygen documented as given twice daily even though it was not being used. The record also included SpO2 entries stating the resident was on a ventilator or trach, although the DON confirmed he had neither, and an RN could not recall when he last used NC oxygen.
Food Storage and Sanitation Deficiencies in Dietary Area
Penalty
Summary
Proper sanitation and food storage practices were not maintained in the facility kitchen. On 03/16/26, the walk-in freezer contained undated breadsticks stored in an unmarked clear bag, and the dry storage area had multiple food items open to air, not sealed, and not dated, including Corn Flakes, Bran Flakes, Lays Classic chips, all-purpose flour, and three unlabeled, undated bags containing a brown-colored substance. The Dietary Manager stated, "I am not sure what that could be." On 03/17/26, the Dietary Manager verified grease residue along the side of the grill, spilled sherbet on the walk-in freezer floor, and peeling paint on the walk-in cooler floor under stored milk. A Dietary Aide stated he did not remember seeing the posted cleaning schedule. Additional observations showed improper food storage above the prep area, including an open, unsealed box of corn starch and undated containers of Italian seasoning, cilantro leaves, black pepper, cinnamon, and ground mustard, along with grime on the bottles and crumbs on the prep shelf. On 03/23/26, a dented six-pound can of sliced apples was observed on the shelf for active use, and the Dietary Aide verified it had been kept for use even though dented cans were supposed to be placed by the outgoing kitchen door for pickup and disposal. The ice machine also had a dark residue on the plastic lip inside that transferred to a paper towel when wiped, and the Dietary Aide was unsure whether a tracking sheet existed for emptying and cleaning the ice machine. Facility checklists and the sanitation policy required clean and sanitary food service areas, labeled and dated food items, and regular cleaning of surfaces and equipment.
Cold Sink Water in Resident Rooms
Penalty
Summary
The facility failed to maintain a comfortable, homelike environment when water temperatures in resident rooms were cold at the sink. During observations and interviews, Resident #24 reported that the sink water in her room did not get warm unless it ran for a long time, and the water remained cold even after running for over two minutes. Resident #26 and Resident #14 also had sink water that was cold and remained cold after running for approximately five minutes, which was confirmed by CNA #518. Resident #46 stated that the bathroom sink water did not get hot, and the shelf beside the sink had dirty adaptive equipment. Resident #42’s room also had low water temperature, with the sink water reaching only 99.2 degrees F after five minutes of running, and an unoccupied room on the same hall reached 98.7 degrees F after three minutes, as confirmed by the Maintenance Supervisor. The Maintenance Supervisor stated he noticed a bad circulation tank for the water system on 03/13/26 and had called a plumber to come to the facility on 03/16/26. He also stated he did not view the water temperature as a problem because residents would shower in the shower room and CNAs would mainly use the sinks. On interview, he said he completed weekly water temperature checks in rooms but did not mark which rooms he tested, and if temperatures were too high or too low he would adjust them or bleed off the line, without documenting the temperatures or follow-up maintenance. Facility records showed hot water temperatures of 103 degrees F on 01/15/26 and 104 degrees F on 03/13/26. The facility policy required resident room water temperatures to be between 105 and 120 degrees F and maintenance staff to record temperatures in a maintenance log.
Inaccurate MDS Assessments for Antipsychotic Use, Pressure Ulcers, and Insulin Administration
Penalty
Summary
The facility failed to ensure Minimum Data Set (MDS) assessments were accurately completed for two residents. For Resident #7, the medical record showed an admission date of 04/15/25 with diagnoses including depression, dementia, and anxiety. The physician’s orders included Risperdal 0.25 mg at bedtime for paranoia and agitation, and Risperdal was identified as an antipsychotic medication. However, the 02/19/26 modified annual MDS recorded that the resident was taking an antipsychotic in section N415, while section N450 stated that antipsychotics had not been received since admission or the prior assessment. An RN later verified that the MDS entry for section N450 was incorrect because the resident was receiving Risperdal. For Resident #12, the quarterly MDS dated 02/23/26 documented a BIMS score of 13, dependence for several activities of daily living, an indwelling Foley catheter, bowel incontinence, and pressure ulcer risk. The assessment also indicated no pressure ulcer/injury on M0100, but yes for unhealed pressure ulcers on M0210, and it identified one Stage II pressure ulcer present on admission. RN #603 confirmed the resident had two Stage II pressure ulcers at the time of the MDS, with one on the coccyx and one on the buttocks. The MDS also recorded one injection in the prior seven days and insulin on one day, but the medical record showed blood glucose checks on 02/19/26 and 02/20/26 that required subcutaneous Humalog coverage on both days, which RN #603 confirmed.
Failure to Provide Ordered Oxygen and Keep Respiratory Orders Accurate
Penalty
Summary
The facility failed to ensure oxygen was provided to a resident as ordered and failed to keep the resident’s orders and documentation aligned with the current plan of care. Resident #3 was admitted with diagnoses including chronic atrial fibrillation, depression, diffuse traumatic brain injury with loss of consciousness, dysphagia, heart failure, and muscle weakness. The resident’s care plan identified impaired respiratory status related to oxygen dependence, and a physician order dated 12/02/25 directed continuous oxygen at 1 LPM via nasal cannula. However, the MDS special treatment section did not include the frequency of oxygen therapy, and nursing documentation later reflected oxygen use that did not match the resident’s actual condition or equipment needs. Survey observations showed Resident #3 repeatedly without oxygen in place while an oxygen concentrator was present in the room but not being used and positioned where the resident could not access it. On multiple observations, the resident was not wearing oxygen, and at one point appeared pale with cyanotic lips, mottled arms, and minimal responsiveness. The resident stated he did not know whether he was supposed to be on oxygen. The record also contained pulse oximeter entries that incorrectly indicated the resident was receiving oxygen by ventilator or trach, even though the DON confirmed the resident had neither a tracheostomy nor a ventilator. During interviews, the RN stated she checked oxygen saturation daily and could not recall the last time the resident had oxygen by nasal cannula. The MD stated she believed oxygen had been ordered as needed and denied there was an oxygen order, despite having signed the order for continuous oxygen. The DON confirmed nurses had documented the resident as receiving continuous oxygen twice daily from 03/01/26 until the morning of 03/18/26, but also confirmed the resident had not actually been provided the oxygen as ordered during that time. The resident representative stated staff had told the family oxygen was not being left on because it caused agitation, although this was not documented in the medical record.
Inaccurate Oxygen Documentation in Resident Record
Penalty
Summary
The facility failed to maintain an accurate medical record for Resident #3, whose diagnoses included alcohol abuse, dementia, difficulty walking, hypertension, history of falls, dysphagia, heart failure, atrial fibrillation, depression, traumatic brain injury, muscle weakness, and a Stage IV pressure ulcer of the sacral/right buttock region. The resident’s care plan identified impaired respiratory status related to oxygen dependence, with interventions for continuous oxygen via nasal cannula and monitoring of vital signs and pulse oximetry. However, the physician order dated 12/02/25 specified continuous oxygen at 1 LPM via nasal cannula, while the TAR showed nursing staff documented the oxygen as completed twice daily from 03/01/26 through 03/17/26 even though the oxygen was not being used. The record also contained inaccurate pulse oximetry documentation. Readings in the chart included entries indicating the resident was receiving oxygen by ventilator on 01/15/26 and by trach on 01/26/26, although the resident did not have a tracheostomy and was not on a ventilator, as confirmed by the DON. The MDS dated 01/28/26 showed a BIMS score of 12 and indicated the resident was on oxygen, but did not identify the frequency of oxygen therapy. During interview, an RN stated she checked the resident’s SpO2 daily and could not recall the last time he had oxygen by nasal cannula, and the DON confirmed the documentation showed oxygen use that had not actually occurred.
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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 East Liverpool
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stone Pear Pavilion | 1.2 mi | ★★★★★ | 18 | 0 |
| Orchards Of East Liverpool, The | 1.3 mi | ★★★★★ | 9 | 0 |
| Calcutta Health Care Center | 3.9 mi | ★★★★★ | 2 | 1 |
| Beaver Valley Rehabilitation And Healthcare Center | 11.9 mi | ★★★★★ | 29 | 1 |
| Friendship Rehab And Health | 13.5 mi | ★★★★★ | 53 | 1 |
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