Shepherd of the Valley Liberty

In the surveyor’s words

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

• Actual harm, isolatedF689Oct 5, 2023

  Based on observation, record review, interview, and facility policy review the facility failed prevent a fall with injury for Resident #20. Actual Harm occurred on 07/13/23 when Resident #20 who required extensive assistance of one person for bed mobility, did not have fall prevention interventions in place, fell from bed and sustained large left periorbital and front scalp hematomas (an injury that causes blood to collect and pull under the skin) and a fracture involving the left orbital roof extending into the left frontal sinus. This affected one resident (#20) of three residents reviewed for falls. […]

• No harm, potential for more than minimal, widespreadF812Sep 22, 2025

  Based on observation, interview and record review, the facility did not ensure food was stored, prepared and served in accordance with professional standards for food safety. This had the potential to affect 54 residents who received meals from the kitchen. The facility identified seven residents (Resident #19, #6, #8, #33, #70, #71 and #1) who received nothing by mouth (NPO). The facility census was 61. Findings Include:Observation on 09/15/25 at 9:54 A.M. of the dry food storage room in the main kitchen revealed the following food items were not dated with the date received: four one-gallon tubs of mayonnaise, one one-gallon Caesar salad dressing tub, one one-gallon Thousand Island dressing tub, two seven-pound five-ounce cans of jellied cranberry sauce, two six-pound cans of diced… […]

• No harm, potential for more than minimal, widespreadF835Sep 22, 2025

  Based on record review and interview, the facility administration failed to ensure an effective system was in place to maintain current cardiopulmonary resuscitation (CPR) certification for the licensed nurses for the highest practicable well being of all residents. This had the potential to affect all 61 residents residing in the facility. Findings include:Review of personnel files on [DATE] at 2:39 P.M. with Human Resources Director (HRD) #742 revealed Licensed Practical Nurse (LPN) #694's CPR (cardiopulmonary resuscitation) certification expired 03/2025 and was renewed on [DATE]. LPN #696's CPR certification expired [DATE] and was renewed on [DATE]. LPN #684's CPR certification expired 02/2025 and was renewed on [DATE]. […]

• No harm, potential for more than minimal, widespreadF921May 21, 2025

  Based on observation, interview and record review the facility failed to maintain a clean environment, including mechanical lifts. This affected Resident #3 and had the potential to affect all 65 residents residing in the facility. Findings include: On 05/07/25 between 9:30 A.M. and 10:30 A.M. an initial tour of the building was conducted with the Assistant Director of Nursing (ADON) #112. Resident #3's room was noted to have a dirty floor with visible crumbs and a visible dust buildup behind the door. The toilet in Resident #3's room was noted to have a yellow and streaks around the outer bowl of the toilet. There was also a brown spot on the wall between the toilet and the sink that appeared to be dried feces. […]

• No harm, potential for more than minimal, widespreadF868Jul 29, 2021

  Based on record review, staff interview, and review of facility policy the facility failed to ensure they met quarterly for the Quality Assurance and Performance Improvement (QAPI) committee and failed to have the Medical Director in attendance. This had the potential to affect all 55 residents currently residing in the facility. Findings include: Review of the QAPI meeting attendance sign in sheets from 07/29/20 through 07/29/2021 revealed the facility only met on 04/29/21 and 07/21/21. There was no Medical Director signature on the 04/29/21 minutes. Interview on 07/29/21 at 4:15 P.M. with the Director of Clinical Services (DCS) #900 verified the facility only met on 04/29/21 and 07/21/21 and she stated she believed due to the COVID-19 pandemic they did not have to meet. […]