Shepherd of the Valley Rehabilitation and Wellness

In the surveyor’s words

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

• Immediate jeopardy, patternF689Mar 13, 2026

  Based on observation, staff interview, incident report review, medical record review, manufacturer's recommendation review, and mechanical lift reference guide review, the facility failed to ensure safe staff practices and safe working condition of assistive devices for 1 of 4 sample residents (#1) reviewed for accident hazards. This failure resulted in a cervical fracture to resident #1 who fell during a mechanical lift transfer which resulted in the determination of immediate jeopardy due to a failure to follow manufacturer's instructions for safe mechanical lift transfers. Corrective measures were implemented prior to the survey and compliance was determined to be met on 2/16/26. The findings were: 1. […]

• Immediate jeopardy, patternF880Feb 10, 2022

  Based on observation, review of facility infection control documentation, staff interview, review of policy and procedures, and CDC guidelines, the facility failed to ensure transmission-based precautions were followed consistently and correctly to prevent the spread of communicable disease. This failure resulted in an unacceptable risk to resident health and a determination of immediate jeopardy. In addition the facility failed to ensure acceptable infection control practices were followed related to hand hygiene during 1 observation of meal service. The census was 140. The findings were: 1. […]

• Actual harm, isolatedF600Jul 30, 2026

  Based on resident representative and staff interview, medical record review, facility incident review, and policy review, the facility failed to ensure residents were free from abuse from other residents for 1 of 8 sample residents (#37) reviewed for abuse. This failure resulted in actual harm to resident #37. The findings were: The facility had implemented corrective action prior to the survey and was determined to be in substantial compliance as of 7/17/26. 1. Review of the annual MDS assessment dated [DATE] showed resident #37 had a BIMS score of 3 out of 15, which indicated severe cognitive impairment, and had diagnoses which included non-Alzheimer's dementia, depression, and psychotic disorder. Further review showed the resident had behaviors of wandering daily. […]

• Actual harm, isolatedF600May 22, 2025

  Based on medical record review, resident representative and staff interview, facility incident review, and performance improvement plan review, the facility failed to protect the residents' right to be free from physical abuse by another resident for 1 of 8 sample residents (#12). This failure resulted in actual harm to resident #12. Corrective measures were implemented prior to the survey and compliance was determined to be met on 5/16/25. The findings were: 1. Review of the discharge MDS assessment dated [DATE] for resident #12 showed the resident admitted to the facility on [DATE] and a brief interview for mental status score of 2 out of 15, which indicated severe cognitive impairment. […]

• Actual harm, isolatedF580Mar 20, 2025

  Based on resident representative and staff interview, medical record review, and policy review, the facility failed to notify residents' physicians with changes of condition or treatment for 2 of 10 sample residents reviewed (#9, #10). This failure resulted in actual harm to resident #9 who required additional surgical intervention. The findings were: 1. Review of the admission MDS assessment dated [DATE] showed resident #9 had a BIMS score of 15 out 15, which indicated the resident was cognitively intact, and had diagnoses which included wound infection, displaced simple supracondylar fracture without intercondylar fracture of the right humerus, unspecified open wound of the right elbow, and methicillin resistant staphylococcus aureus. […]