Inspection·May 21, 2025

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to maintain a clean environment, including mechanical lifts. This affected Resident #3 and had the potential to affect all 65 residents residing in the facility. Findings include: On 05/07/25 between 9:30 A.M. and 10:30 A.M. an initial tour of the building was conducted with the Assistant Director of Nursing (ADON) #112. Resident #3's room was noted to have a dirty floor with visible crumbs and a visible dust buildup behind the door. The toilet in Resident #3's room was noted to have a yellow and streaks around the outer bowl of the toilet. There was also a brown spot on the wall between the toilet and the sink that appeared to be dried feces. The baseboards in the 500 hall were noted to have a white dust buildup on them. The fireplaces in the 500 and 600 halls were noted to have a heavy dust buildup at the bases of each unit. The table in the hall between the skilled nursing unit and the common area was noted to have a heavy dust buildup on the bottom ring. There were no housekeepers noted in the resident areas. The [NAME] lift (a mechanical lift devise used to assist residents from a sit to stand position) located in the 500 hall was noted to have a white buildup on each of the side pads and a dirt buildup on the foot rest. A Hoyer lift (a mechanical lift utilized to lift a resident) located in the 500 hall was noted to have a visible dirt buildup at the base and a buildup ,of visible crumbs and debris on the foot rest. A Hoyer lift located in room [ROOM NUMBER] was noted to have a visible dirt build up at the base of the unit. The aforementioned findings were verified by ADON #112 at the time of the observation. On 05/07/25 at 10:35 A.M. an interview with Environmental Services Supervisor (ESS) #165 revealed resident rooms do not get cleaned every day. They get cleaned every three days. ESS #165 stated housekeeping services are subcontracted out to Serve Pro. ESS #165 stated he audits five rooms daily for cleanliness. ESS #165 also stated Serve Pro sends him pictures of rooms that were cleaned as they are completed. ESS #165 stated Resident #3's was cleaned on 05/05/25 and had pictures of the bathroom. A review of the photo titled the room number Resident #3 resided in revealed the toilet had visible brown and yellow streaks on the outer bowl. The photo also revealed the brown spot located on the wall between the toilet and the sink in Resident #3's room. ESS #165 verified the visible brown and yellow streaks on the outer bowl of the toilet and the brown spot located on the wall between the toilet and the sink in the picture. ESS #165 stated the porter is responsible for baseboard, fireplace and table cleaning. ESS #165 stated there is no set schedule for the porter cleaning but if they see dust they should clean it. On 05/07/25 at 10:45 A.M. an interview with Serve Pro Manager (SPM) #161 revealed housekeeping was (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 365298 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365298 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shepherd of the Valley Liberty 1501 Tibbetts Wick Road Girard, OH 44420 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)