Libby Care Center

In the surveyor’s words

From the most serious findings on record at Libby Care Center, in the surveyor’s own words.

• Actual harm, isolatedF697Jun 29, 2026

  Based on observations, interviews, and record reviews, the facility failed to ensure a resident's pain was managed in accordance with the resident's care plan and preferences for 1 (#57) of 23 sampled residents. This deficient practice resulted in resident #57 having moderate to severe pain from a fracture. This deficient practice increased the likelihood of other residents with pain not being managed. Findings include:During an observation and interview on 6/27/26 at 3:48 p.m., resident #57 was sitting in her recliner in her room. Resident #57 stated she was in pain due to a fractured elbow. Resident #57 rated her pain level as 6 out of 10 (moderate pain). […]

• Actual harm, isolatedF600Aug 17, 2023

  Based on interview and record review, the facility failed to initiate interventions to prevent physical abuse for 2 (#s 67 and 237), resulting in 1 (#67) getting a broken nose, out of 2 sampled residents; and failed to complete an assessment after the altercation, for 1 (#237) out of 2 sampled residents, as well as not letting him return to the facility after the incident. Findings include: A facility reported incident, dated 6/9/23 at 3:35 p.m., showed: Incident Description: .(Resident #67) was found in his room with a bloody nose; he does have a diagnosis of dementia but states 'He just turned around and hit me.' The 'he' he was referring to was his roommate (Resident #237) who was no longer in the room. […]

• Actual harm, isolatedF689Aug 17, 2023

  Based on observation, interview, and record review, facility licensed nursing staff failed to thoroughly assess two residents for ensuring necessary transport services were provided when residents sustained fractures and head injuries during falls, and the residents were manually pushed in their wheelchairs by a nurse or CNA, to the ER, causing increased pain and risk of further injury due to inappropriate transports, for 2 (#s 238 and 239) of 3 sampled residents; and the ER later reported #238 had fractures in her back. […]

• No harm, potential for more than minimal, widespreadF880Jun 29, 2026

  Based on observation, interview, and record review, the facility failed to ensure the washer area of the laundry room was clean and kept free of debris; and the facility staff failed to ensure proper glove use and hand hygiene during glucose testing process for 1 (#65) of 23 sampled residents. This failure had a likelihood of contaminating resident clothes and facility linens while being washed and transferred to the dryer and increased the risk of bloodborne pathogen contamination and/or infection for residents receiving care on the 100-hall unit. Findings include:1. During an observation and interview on 6/28/26 at 8:00 a.m., staff member F was preparing to check the blood sugar of resident #65. […]

• No harm, potential for more than minimal, widespreadF880Jun 30, 2025

  4. During an observation and interview on 6/28/25 at 2:50 p.m., the Team 2 medication room was found to have a variety of supplies and medications stacked in the corner and on the floor of the room which was an infection control concern. Staff member C said the room was too small for the amount of medication and supplies stored in the room. Staff member C said she asked administration for shelving to be able to provide more room for medication storage, but it had not been provided, so the items remained on the floor. During an observation and interview on 6/29/25 at 9:52 a.m., the Team 1 medication room had a variety of supplies covering the countertop. A used, personal cup, was in the sink. […]