Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of June 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.
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.
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.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the citations issued around you in the last 12 months — including the immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Libby Care Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.