Shepherd Of The Valley Howland

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and review of the facility policy, the facility failed to ensure Resident #36's advance directives were accurate. This affected one (Resident #36) out of two residents reviewed for advance directives. The facility census was 44. Findings include: Review of the medical record for Resident #36 revealed an admission date of [DATE] with diagnoses including dementia, spinal stenosis, and history of myocardial infarction. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #36 had impaired cognition. Review of the care plan dated [DATE] revealed Resident #36's was a full code. Interventions included Resident #36 was a full code and cardiopulmonary resuscitation (CPR) was to be initiated and review advance directives periodically with resident and/or family. Review of the Do Not Resuscitate Comfort Care (DNRCC) form dated [DATE] and completed by Medical Director/Primary Care Physician (PCP) #619 revealed Resident #36 advance directive indicated he…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview and review of the facility policy, the facility failed to ensure Resident #27's bowel elimination was monitored effectively. This affected one (Resident #27) out of one resident reviewed for constipation. The facility census was 44. Findings include: Review of the medical record for Resident #27 revealed an admission date of 10/28/22 with diagnoses including fractured right femur, gastroenteritis, colitis (inflammation of the colon), Alzheimer's disease, melena (black tarry stool), and diverticulosis (small, bulging pouches in the lining of the large intestine). Review of the care plan dated 11/04/22 revealed Resident #27 was at risk for constipation due to medication side effects, reduced mobility, weakness, colitis, and diverticulosis. Interventions included assessing and monitoring the resident's abdomen for distension, bowel sounds as ordered, assessing and monitoring bowel movements every shift, assessing and monitoring for medication side effects for constipation,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and facility policy review, the facility failed to post oxygen safety signs per acceptable standards of nursing practice. This affected three (Residents #101, #103 and #105) out of three residents reviewed for respiratory care. There were eight (Residents #4, #5, #10, #13, #33, #101, #103 and #105) who received oxygen therapy. The facility census was 44. Findings include: Observation on 06/02/25 at 10:33 A.M. with Registered Nurse (RN) #567 revealed Residents #101 and #103 were in bed with oxygen being administered, and there were no oxygen safety signs posted within the room or at the entrances. Resident #105 was in a wheelchair next to the bed with oxygen being administered and there was no oxygen safety sign posted within the room or at the entrance. Interview at the time of the observation with RN #567 verified the findings. Review of the medical record for Resident #101 revealed an admission date of 05/10/25. Diagnoses included chronic respiratory failure, chronic obstructive pulmonary disease (COPD), emphysema and congestive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review and facility policy review, the facility failed to perform adequate infection control practices during urinary catheter care for Resident #3. This affected one (Resident #3) out of two residents reviewed for urinary catheter care. There were two (Residents #3 and #36) who had urinary catheters. The census was 44. Findings include: Review of the medical record for Resident #3 revealed an admission date of 04/30/25. Diagnoses included neuromuscular dysfunction of the bladder, benign prostatic hyperplasia and end stage renal disease. The plan of care dated 04/30/25 indicated Resident #3 had a chronic urinary catheter which required catheter care and management. Observation on 06/03/25 at 10:03 A.M. with Certified Nursing Assistants (CNAs) #512 and #544 of urinary catheter care for Resident #3 revealed the resident in bed and both CNAs had donned gloves and gowns for enhanced barrier precautions. CNA #512 lowered Resident #3's pants and opened a soiled brief to expose the urinary catheter. CNA #512 used cleanser and disposable wipes to wash…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure food items were dated when opened. This had the potential to affect the 52 residents who ate food from the kitchen. Resident #37 was identified by the facility as receiving nothing by mouth. The facility census was 53. Findings include: Observation of the kitchen on 01/17/23 from 8:10 A.M. to 8:30 A.M. with Dietary [NAME] #35 revealed the walk-in cook's freezer had one undated, half-full resealed bag of pork sausage links, one undated resealed bag of three breaded fish fillets, one undated half-full resealed bag of green peppers, and one undated half-full resealed bag of tator tots. The reach-in cooler by the toaster had one undated storage bag with sliced pastrami. The walk-in dietary aide's cooler had one undated resealed bag of whipped topping. The walk-in dietary aide freezer had one undated storage bag of five sausage links, one undated storage bag of seven sausage links, one undated storage bag of five sausage patties, and one undated storage bag of six chicken quarters. At the time of these…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure Resident #40 received reading material as requested and was not given the opportunity to implement her normal bowel regimen. The facility failed to ensure Resident #256 received showers as preferred. This affected two of three residents reviewed for choices. The facility census was 55. Findings include: 1. Resident #40 was admitted to the facility on [DATE] with a fractured to her left foot. Review of the medical record, including the nursing notes, assessments, initial care plan meeting from 11/27/19 through 01/02/19 revealed there was no evidence of the resident's below ongoing concerns. Review of the admission minimum data set (MDS) 3.0 dated 12/04/19 revealed the resident was totally dependent on two or more staff for activities of daily living (ADL's) including transfers and toileting. On 12/31/19 at 7:40 A.M., interview with Resident #40 revealed she was having trouble with her bowels and she needed a fleets enema (a laxative…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to report an injury of unknown origin to the State agency as required. This finding affected two (Residents #12 and #257) of five resident records reviewed for accidents. The facility census was 55. Findings include: 1. Review of Resident #12's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including heart failure, unspecified dementia with behavioral disturbance and paranoid schizophrenia. Review of Review #12's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment. Review of Resident #12's progress note dated 08/02/19 at 10:55 P.M. indicated the staff alerted the nurse the resident had a bruise to the right forearm and to the left foot. The resident was alert to self only and was unable to voice a cause for the injury. The bruise to the right arm was irregular in shape and spanned from the antecubital space to the inferior deltoid measuring approximately…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to thoroughly investigate an injury of unknown origin for Resident #257. This affected one of two residents reviewed for IUO. The facility census was 55. Findings included: Resident #257 was admitted to the facility on [DATE] with diagnoses which included a fracture of her right upper arm due to a fall at home. Review of the physicians order dated 12/11/19 revealed Resident #257 was to be transferred with two staff at all times. Review of the physical therapy (PT) and occupational therapy (OT) notes dated 12/13/19 revealed the resident was assessed for standing tolerance and there was no indicate of pain to either of her legs. Further review of the PT note dated 12/15/19 revealed the resident complained of pain at the start of therapy of a score of nine out of 10. The nurse provided pain medication during the therapy session but there was no evidence of an assessment completed for the new pain. Further review of the OT note dated 12/16/19 revealed the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not ensure Resident #252's wound care was completed as indicated in the physician orders. This finding affected one (Resident #252) of two residents reviewed for pressure ulcers. The facility census was 55. Findings include: Review of Resident #252's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including anxiety disorder, pressure ulcer of other site and unspecified atrial fibrillation. Review of Resident #252's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated the resident exhibited moderate cognitive impairment and had one stage three pressure ulcer (wound that had broken completely through the two top layers of the skin and into the fatty tissue below). Review of Resident #252's physician order dated 12/03/19 indicated to cleanse the right gluteal fold wound with normal saline, prep the peri wound with skin prep, apply Flagyl 0.75% (percent) spray (hospice to provide) to wound bed, lightly pack with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure Resident's #40, #256 and #257 were transferred according to their care plans for optimal safety. This affected three of five residents revealed for accidents. The facility census was 55. Findings included: 1. Resident #40 admitted to the facility on [DATE] with diagnoses which included a left foot fracture. Review of the physicians order initiated 11/27/19 revealed the resident was non-weight bearing on the left foot. Review of the physicians order dated 12/05/19 revealed to transfer Resident #40 using a slide board and two staff. Review of the admission minimum data set (MDS) 3.0 dated 12/04/19 revealed Resident #40 was totally dependant on two or more staff for activities of daily living (ADL's) including transfers. On 12/31/19 at 7:40 A.M., Resident #40 was observed in the wheelchair with her left foot wrapped and elevated on a leg rest. On 12/31/19 at 7:41 A.M., interview with Resident #40 verified she was to be transferred using…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure proper justification for the continued use of Resident #256 indwelling urinary catheter. This affected one of one residents reviewed for indwelling catheters. The facility census was 55. Findings include: Resident #256 was admitted to the facility on [DATE] after a hospital stay for a new onset of a stroke which affected the use of the resident's left arm and leg and her speech. Review of the hospital documentation dated 12/05/19 revealed there was no evidence of a history of an indwelling urinary catheter prior to this hospital stay nor any diagnoses to support the on-going use of the catheter. The resident was not able to talk but was able to communication using a dry erase board. Review of the admission physician orders dated 12/16/19 revealed Resident #256 had an indwelling urinary catheter. Review of the nurse's note dated 12/16/19 revealed the physician was contacted again to verify need to continue the indwelling urinary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.