Girard, OH

Shepherd Of The Valley Liberty

3-star overall rating with 3-star inspections with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle

1501 Tibbetts Wick Road, Girard, OH

(330) 544-0771

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

4 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

79

Certified beds

Average residents

64

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

1974-09-03

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.72

Registered nurse staffing · state 0.63 · national 0.68

LPN hours / resident day

1.36

Licensed practical nurse staffing · state 0.96 · national 0.87

Aide hours / resident day

2.37

Nurse aide staffing · state 2.14 · national 2.35

Total nurse hours

4.45

All reported nurse hours · state 3.72 · national 3.89

Licensed hours

2.08

RN + LPN hours · state 1.59 · national 1.54

Weekend hours

3.80

Weekend nurse staffing · state 3.29 · national 3.43

Weekend RN hours

0.37

Weekend registered nurse coverage · state 0.41 · national 0.47

Physical therapist

0.03

Reported PT staffing · state 0.05 · national 0.07

Adjusted RN hours

0.67

CMS adjusted RN staffing hours

Adjusted total hours

4.11

CMS adjusted total nurse staffing hours

Case-mix index

1.48

Higher values indicate more complex resident acuity

RN turnover

11%

Annual RN turnover · state 47% · national 45%

Total nurse turnover

53%

Annual nurse turnover · state 50% · national 46%

SNF VBP

Value-based purchasing

Program rank

4,787

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

38.57

Composite VBP score used to determine payment impact.

Payment multiplier

0.9916

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

4.36

Baseline 17.80% · Performance 19.41% · Measure score 4.36 · Achievement 4.36 · Improvement 0

Healthcare-associated infections

7.44

Baseline 4.96% · Performance 5.61% · Measure score 7.44 · Achievement 7.44 · Improvement 0

Total nurse turnover

2.12

Baseline 55.84% · Performance 55.00% · Measure score 2.12 · Achievement 2.12 · Improvement 0

Adjusted total nurse staffing

1.50

Baseline 3.68 hours · Performance 3.51 hours · Measure score 1.50 · Achievement 1.50 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	12.09%	10.72% 1.4 pts worse	No Different than the National Rate · Eligible stays 148 · Observed rate 14.19% · Lower 95% interval 9.34%
Discharge to community	54.95%	50.57% 4.4 pts better	No Different than the National Rate · Eligible stays 155 · Observed rate 50.32% · Lower 95% interval 45.68%
Medicare spending per beneficiary	0.96	1.02 0.1 pts better
Drug regimen review with follow-up	100%	95.27% 4.7 pts better	Numerator 98 · Denominator 98
Falls with major injury	1.02%	0.77% 0.2 pts worse	Numerator 1 · Denominator 98
Discharge self-care score	28.17%	53.69% 25.5 pts worse	Numerator 20 · Denominator 71
Discharge mobility score	50.7%	50.94% 0.2 pts worse	Numerator 36 · Denominator 71
Pressure ulcers or injuries, new or worsened	1.02%	2.29% 1.3 pts better	Numerator 1 · Denominator 98 · Adjusted rate 1.1%
Healthcare-associated infections requiring hospitalization	5.61%	7.12% 1.5 pts better	No Different than the National Rate · Eligible stays 85 · Observed rate 2.35% · Lower 95% interval 2.8%
Staff COVID-19 vaccination coverage	0.84%	8.2% 7.4 pts worse	Numerator 1 · Denominator 119
Staff flu vaccination coverage	34.54%	42% 7.5 pts worse	Numerator 86 · Denominator 249
Discharge function score	22.54%	56.45% 33.9 pts worse	Numerator 16 · Denominator 71
Transfer of health information to provider	98.15%	95.95% 2.2 pts better	Numerator 53 · Denominator 54
Transfer of health information to patient	100%	96.28% 3.7 pts better	Numerator 23 · Denominator 23
Resident COVID-19 vaccinations up to date	4.65%	25.2% 20.5 pts worse	Numerator 2 · Denominator 43

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	0.4	1.8 1.4 pts better	1.9 1.5 pts better	Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.6 · Expected 2.6 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	2.3	1.8 0.5 pts worse	1.8 0.5 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.3 · Observed 2.8 · Expected 2.0 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	95.6%	92.4% 3.2 pts better	93.4% 2.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 96.1% · Q2 98.0% · Q3 96.0% · Q4 92.5% · 4Q avg 95.6%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	94.5%	94.5% About the same	95.5% 1 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 94.5%
Percentage of long-stay residents experiencing one or more falls with major injury	2.5%	3.3% 0.8 pts better	3.3% 0.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 3.9% · Q2 4.0% · Q3 2.0% · Q4 0.0% · 4Q avg 2.5% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	3.9%	26.1% 22.2 pts better	11.4% 7.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 4.5% · Q3 4.3% · Q4 2.2% · 4Q avg 3.9%
Percentage of long-stay residents who lose too much weight	3.8%	6.2% 2.4 pts better	5.4% 1.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.3% · Q3 7.9% · Q4 2.4% · 4Q avg 3.8%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	29.4%	25.4% 4 pts worse	19.6% 9.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 30.2% · Q2 31.6% · Q3 28.9% · Q4 26.8% · 4Q avg 29.4%
Percentage of long-stay residents who received an antipsychotic medication	2.1%	11.5% 9.4 pts better	16.7% 14.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 5.7% · Q2 2.9% · Q3 0.0% · Q4 0.0% · 4Q avg 2.1% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.1% 0.1 pts better	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	26.5%	7.7% 18.8 pts worse	16.3% 10.2 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 26.5% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	10.2%	6.2% 4 pts worse	14.9% 4.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 11.4% · Q2 15.6% · Q3 3.4% · Q4 9.4% · 4Q avg 10.2% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	1.0%	0.2% 0.8 pts worse	1.0% About the same	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.4% · Q3 1.8% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	2.9%	0.5% 2.4 pts worse	1.7% 1.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 4.0% · Q3 2.0% · Q4 3.8% · 4Q avg 2.9% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	44.3%	21.7% 22.6 pts worse	19.8% 24.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 50.1% · Q2 42.4% · Q3 42.0% · Q4 42.5% · 4Q avg 44.3%
Percentage of long-stay residents with pressure ulcers	4.8%	3.7% 1.1 pts worse	5.1% 0.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 7.6% · Q3 8.7% · Q4 1.3% · 4Q avg 4.8% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	89.6%	78.1% 11.5 pts better	81.7% 7.9 pts better	Short Stay · 2024Q4-2025Q3 · Q1 89.9% · Q2 90.1% · Q3 90.5% · Q4 87.9% · 4Q avg 89.6%
Percentage of short-stay residents who had an outpatient emergency department visit	17.0%	12.5% 4.5 pts worse	12.0% 5 pts worse	Short Stay · 20240701-20250630 · Adjusted 17.0% · Observed 16.2% · Expected 10.7% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.7%	1.2% 0.5 pts better	1.6% 0.9 pts better	Short Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 1.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	94.1%	75.6% 18.5 pts better	79.7% 14.4 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 94.1%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	29.0%	25.1% 3.9 pts worse	23.9% 5.1 pts worse	Short Stay · 20240701-20250630 · Adjusted 29.0% · Observed 29.7% · Expected 24.4% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-09-22 · Fire 2025-09-22

9 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

4 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 2 Health 2023-10-05 · Fire 2023-10-05

6 health deficiencies

Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)

2 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 3 Health 2021-07-29 · Fire 2021-07-29

3 health deficiencies

Top issue: Administration (1 deficiency)

4 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-09-22

E39 · Emergency Preparedness Deficiencies

Fire Safety

Conduct testing and exercise requirements.

Corrected 2025-12-05

F · Potential for more than minimal harm 2025-09-22

K926 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk.

Corrected 2025-12-05

E · Potential for more than minimal harm 2025-09-22

K222 · Egress Deficiencies

Fire Safety

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Corrected 2025-12-05

E · Potential for more than minimal harm 2025-09-22

K321 · Smoke Deficiencies

Fire Safety

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Corrected 2025-12-05

E · Potential for more than minimal harm 2023-11-15

K915 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper power supply for life support equipment.

Corrected 2024-06-01

F · Potential for more than minimal harm 2023-10-05

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-10-24

F · Potential for more than minimal harm 2023-10-05

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-10-24

F · Potential for more than minimal harm 2021-07-29

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2021-08-13

E · Potential for more than minimal harm 2021-07-29

K355 · Smoke Deficiencies

Fire Safety

Properly select, install, inspect, or maintain portable fire extinguishes.

Corrected 2021-08-13

E · Potential for more than minimal harm 2021-07-29

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2021-08-13

Inspection history

Recent health citations

F · Potential for more than minimal harm 2025-09-22

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2025-12-05

F · Potential for more than minimal harm 2025-09-22

F835 · Administration Deficiencies

Health

Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Corrected 2025-12-05

E · Potential for more than minimal harm 2025-09-22