Shepherd of the Valley-Boardman

In the surveyor’s words

From the most serious findings on record at Shepherd of the Valley-Boardman, in the surveyor’s own words.

• Actual harm, isolatedF686Dec 31, 2025

  Based on observation, record review, interview and review of facility policy, the facility failed to implement an effective pressure ulcer prevention program to promote healing and to ensure Resident #51, who was cognitively impaired, dependent on staff for hygiene and had functional limitation to bilateral upper extremities, received interventions to prevent skin breakdown, timely assessments to her right third and fourth finger wounds and wound care as ordered by the physician.Actual Harm occurred on 10/08/25 when Resident #51 was assessed by Nurse Practitioner (NP) #301 and found to have long nails on her right hand digging into her hand causing wounds (no size or wound type provided in documentation). […]

• No harm, potential for more than minimal, widespreadF761Dec 31, 2025

  Based on observation, staff interview, and facility policy review the facility did not ensure medications were not stored expired and were stored securely in medication storage areas. This affected four of four medication carts observed and had the potential to affect all residents in the facility. The facility census was 49.Findings include: 1. An observation on [DATE] at 10:00 A.M. of the 300 Hall medication cart revealed the following: an opened bottle of Geri-Care acetaminophen (a non-narcotic pain medication) 1000 milligram (mg) tablets with an expiration date of 11/2025, two packets of Medline 0.9 ounce (oz) lubricating jelly with an expiration date of 08/2022, two packets of Medline 0.9 oz lubricating jelly with an expiration date of [DATE], a packet of Medline 0.9oz lubricating… […]

• No harm, potential for more than minimal, patternF638Dec 31, 2025

  Based on record review, interview, and review of the Long-Term Care Resident Assessment Instrument (LTC RAI) 3.0 User's Manual, the facility failed to complete non-comprehensive Minimum Data Set (MDS) assessments in a timely manner. This affected four residents (#2, #8, #25, and #26) out of four residents reviewed for non-comprehensive resident assessments. The facility census was 49.Findings include:1. Review of the medical record for Resident #2 revealed an admission date of 11/03/20 with diagnoses including cerebral infarction, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, hypertension, altered mental status, and dysphagia. […]

• No harm, potential for more than minimal, patternF842Dec 31, 2025

  Based on observation, record review, interview and review of facility policy, the facility failed to ensure accurate documentation in the medical records for Resident #4, #8, #47 and #51. This affected four residents (Residents #4, #8, #47 and #51) out of 25 residents reviewed for resident records. The facility census was 49. Findings include:1. Review of the medical record for Resident #51 revealed an admission date of 02/21/23 with diagnoses including diabetes mellitus, congestive heart failure, peripheral vascular disease and contracted hands. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #51 had impaired cognition. […]

• No harm, potential for more than minimal, isolatedF550Dec 31, 2025

  Based on record review, observation, interview and review of facility policy, the facility failed to honor Resident #13's rights regarding choosing when to get out of bed. This affected one resident (#13) out of five residents reviewed for activities of daily living (ADL). The facility census was 49.Findings include:Review of the medical record for Resident #13 revealed an admission date of 12/26/24 with diagnoses including dementia, repeated falls, muscle weakness, hypertension, glaucoma, age-related osteoporosis, and personal history of transient ischemic attack (stroke). Review of the care plan revised 01/13/25 indicated Resident #13 had impaired self-performance abilities for ADL due to repeated falls, weakness, and osteoporosis. […]