Inspection·July 29, 2021

F 0623 the facility. Level of Harm - Minimal harm or potential for actual harm Review of progress notes dated 05/09/21 revealed Resident #63's lower left extremity was mottled and cold. The physician was called and an order was obtained to send to the emergency room for evaluation and treatment. The son was also called and selected preferred hospital. Residents Affected - Some Review of the medical record revealed there was no notification of transfer to the Ombudsman. 4. Review of medical record for Resident #1 revealed an admission date of 08/01/19 and diagnoses included hypertensive heart disease with heart failure, diabetes, chronic kidney disease, and schizoaffective disorder. There was no documentation in her medical record the Ombudsman was notified of her transfer to the hospital on [DATE]. Review of the annual MDS dated [DATE] revealed Resident #1 had impaired cognition. She had verbal, and physical behaviors. Review of nursing notes authored by Licensed Practical Nurse (LPN) #605 dated 06/30/21 at 9:01 A.M. revealed Resident #1 was having emesis with taking of medication and pulling out her intravenous access. Resident #1's Primary Care Physician #606 was notified and ordered to have Resident #1 sent to the emergency room. Review of nursing note authored by Registered Nurse (RN) #607 dated 06/30/21 at 11:29 P.M. revealed Resident #1 was admitted to the hospital with a diagnosis of failure to thrive. Interview on 7/29/21 at 8:52 A.M. with Admissions/Marketing coordinator #310 revealed she had been sending the list of transfers and discharges to the Ohio Department of Health (ODH). She had not sent the list of transfers and discharges to the Ombudsman. Admissions/Marketing coordinator #310 was not aware that needed to be done. Review of facility policy labeled, Procedure for Bed Hold/ Transfer Notice Notification dated 05/15/18 revealed nearly all hospital transfers, even if planned, would be considered facility initiated and a list of transfers would be emailed to the Ombudsman within 30 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365298 If continuation sheet Page 2 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365298 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shepherd of the Valley Liberty 1501 Tibbetts Wick Road Girard, OH 44420 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly Level of Harm - Minimal harm or potential for actual harm 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. Residents Affected - Many 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. She stated they met virtually prior to this, however, they did not have attendance sheets or minutes. DCS #900 stated the Medical Director was in Florida during the 04/29/21 meeting and there was no evidence he reviewed the meeting minutes on his return. She stated prior to April 2021, the last in person QAPI meeting was held in March 2020. Interview on 07/29/21 at 5:34 P.M. with DCS #900 revealed she found additional QAPI meeting minutes dated 02/10/21 and a signature page which included the Medical Director's signature. She verified they still had not met for quarterly meetings nor had the Medical Director present. Review of the undated facility policy titled Quality Assurance Performance Improvement Plan revealed the committee should be made of the administrative staff, the medical director, and other staff representatives. The policy stated the committee should meet quarterly and maintain an attendance record and meeting minutes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365298 If continuation sheet Page 3 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365298 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shepherd of the Valley Liberty 1501 Tibbetts Wick Road Girard, OH 44420 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0886 Perform COVID19 testing on residents and staff. Level of Harm - Minimal harm or potential for actual harm Based 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. Residents Affected - Many Findings include: Interview on 07/27/21 at 10:06 A.M. with Registered Nurse (RN) #604 and RN/ Infection Control #603 revealed they utilized agency staff routinely at the facility. They revealed they did not track the vaccination or testing status of the agency staff that worked at the facility. They revealed they did not test any of the agency staff that worked at the facility unless the staff wanted to be tested. Interview on 07/28/21 at 10:15 A.M. with Agency STNA #600 revealed she had worked at the facility routinely through an agency. She revealed she was not vaccinated for COVID-19 and stated the facility had not asked her regarding her vaccination status. She confirmed she was not tested by the facility and was last tested over a month ago which was completed at another facility. Interview on 07/28/21 at 11:38 A.M. with Agency STNA #601 revealed she worked at the facility routinely through an agency. She revealed she was not vaccinated for COVID-19 and that the facility had not asked her regarding her vaccination or testing status. She reported she worked at other facilities and it depended if another facility required testing as to how often she was tested. Sometimes it was once a week but other times it was longer. Interview on 07/28/21 at 11:40 A.M. with Agency STNA #602 revealed she was vaccinated but the facility had never asked her for her vaccination status. Interview on 07/29/21 at 9:05 A.M. with the Director of Nursing (DON) and RN #604 verified they did not have COVID-19 testing documentation for unvaccinated Agency STNA #600 and Agency STNA #601 of when they were tested last for COVID-19 or have evidence of Agency STNA #602's vaccination. Review of the facility COVID-19 testing log from 06/01/21 to 07/28/21 revealed the facility did not test or have evidence of when agency staff were tested including Agency STNA #600, and #601. Review of facility policy labeled, Coronavirus Testing last updated 05/05/21 revealed all fully vaccinated staff do not need to be routinely tested. The policy revealed all unvaccinated staff would be tested at least twice per week. The policy did not include how the facility would ensure agency staff was tracked regarding their vaccination or testing status. Review of Ohio Department of Health Amended Directors Order labeled, RE: Director's Amended Order for the Testing of the Residents and Staff of all Nursing Homes dated 05/04/21 revealed each nursing home licensed by the Ohio Department of Health or certified by the United States (U.S.) Department of Health and Human Services Centers for Medicare and Medicaid and Medicaid Services (CMS) shall perform COVID-19 testing for residents and staff in order to protect the health and safety of the residents and staff. The order revealed all unvaccinated staff would be tested at least twice per week. The order revealed unvaccinated referred to a person who does not fit the definition of being fully vaccinated including people whose vaccination status was not known for the purpose of this order. The (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365298 If continuation sheet Page 4 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365298 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/29/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shepherd of the Valley Liberty 1501 Tibbetts Wick Road Girard, OH 44420 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0886 Level of Harm - Minimal harm or potential for actual harm order revealed fully vaccinated staff do not have to be routinely tested. The order defined fully vaccinated staff as a person who was greater than two weeks following receipt of the second dose in a two- dose series or greater than two weeks following receipt of one dose of a single-dose vaccine. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 365298 If continuation sheet Page 5 of 5