Shepherd of the Valley Howland

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Jan 19, 2023

  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 Cook #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. […]

• No harm, potential for more than minimal, isolatedF578Jun 5, 2025

  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. […]

• No harm, potential for more than minimal, isolatedF684Jun 5, 2025

  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. […]

• No harm, potential for more than minimal, isolatedF695Jun 5, 2025

  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. […]

• No harm, potential for more than minimal, isolatedF880Jun 5, 2025

  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. […]