Shepherd of the Valley Liberty

Inspectors wroteBased on record review, resident interview, and staff interview, the facility failed to have a system in place to provide well balanced meals to all residents during a power outage emergency. This affected four residents (#33, #37, #44, and #47) out of four reviewed for diet needs and had the potential to affect all eight residents identified by the facility as having orders for puree diet texture. The facility census was 66.

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, record review and review of facility policy, the facility did not ensure transmission-based precautions were followed by staff during resident care. This affected two residents (#57 and #71) of five residents reviewed for infection control and had the potential to affect an additional nine residents ( #33, #16, #35, #73, #6, #70, #8, #3, and #19) who resided on the 300 and 500 halls . The facility census was 61.

Inspectors wroteBased on observation, record review and interview, the facility did not ensure Resident #28's Power of Attorney (POA) was notified of a change of condition. This affected one resident (#28) of three residents reviewed for change of condition. The facility census was 61.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure assistance from staff was provided to maintain good hygiene for Resident #3. This affected one resident (Resident #3) out of three residents reviewed for assistance with activity of daily living (ADL). The facility census was 61.

Inspectors wroteBased on observation, interview, record review and review of the facility policy the facility failed to ensure thorough post-fall investigations were completed to identify, evaluate and analyze risks, implement appropriate interventions, and monitor for effectiveness of interventions to mitigate risk of subsequent falls for Resident #34. This affected one resident (Resident #34) out of three residents reviewed for falls. The facility census was 61.

Inspectors wroteBased on observation, interview, record review and review of lab reports the facility failed to ensure Resident #28 received appropriate care and services to assess for and treat a urinary tract infection (UTI). This affected one resident (Resident #28) out of four residents reviewed for UTI. The facility census was 61.

Inspectors wroteBased 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.

Inspectors wroteBased 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. The facility census was 60.

Inspectors wroteBased on observation, staff interviews, and facility policy review the facility failed to ensure Residents were fed in a dignified manner. This affected six residents (#5, #18, #21, #22, #37, #50) out of eighteen residents the facility identified as needing physical assistance with meals. The facility census was 60.

Inspectors wroteBased on medical record review, staff interviews, and facility policy review the facility failed to develop comprehensive care plans for Residents #15, #56, #60, and #67. This affected four residents (#15, #56, #60, and #67) out of 20 residents reviewed for care plans. The facility census was 60.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, staff interview, police report review, and facility self-reported incident (SRI) review the facility failed to ensure Resident #43 was free from misappropriation. This affected one resident (#43) out of twenty-one residents reviewed for misappropriation of property. The facility census was 60.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, staff interview, police records review, self-reported incident (SRI) review, and facility policy review the facility failed to ensure their abuse policy was implemented to prevent staff misappropriation of property from Resident #43. This affected one resident (#43) of twenty-one residents reviewed for abuse, neglect, and misappropriation. The facility census was 60.

Inspectors wroteBased on observation, interview, record review, and facility policy review the facility failed to administer oxygen to Resident #15 as ordered by the physician. This affected one resident (#15) of three residents review for respiratory care. The facility census was 98.

Inspectors wroteBased 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.

Inspectors wroteBased on interview, record review and facility policy the facility failed to ensure agency staff were tested for COVID-19 by the facility or verified agency staff vaccination or testing status. This affected two employees (Agency State Tested Nursing Assistant (STNA) #600, and #601) out of three agency employees reviewed and had the potential to affect all 55 residents residing in the facility.

Inspectors wroteBased on medical record review and staff interview the facility failed to ensure the Ombudsman was notified in writing of residents' transfer or discharge to the hospital. This affected four residents (Residents (#1, #17, #32 and #63 ) of four reviewed for hospitalization. The facility census was 55.