Health inspection·August 1, 2023

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility did not ensure Resident #40 received a post-surgical follow up visit with her surgeon in a timely manner. This affected one resident (Resident #40) of three residents reviewed for hospitalization. The facility census was 39. Residents Affected - Few Finding include: Record review for Resident #40 revealed she was admitted to the facility on [DATE] for post-surgical aftercare and rehabilitation following spinal surgery on 05/05/23. Her list of diagnoses upon admission included sepsis, type two diabetes mellitus, spinal stenosis, cirrhosis of the liver, chronic kidney disease stage three, history of bacteremia, multidrug resistant organisms, urinary tract infection, splenial megaly, anemia and hypothyroidism. Resident #40 was discharged to the hospital on [DATE] at the request of her family for an evaluation. Review of physician orders from 05/09/23 to 05/26/23 revealed an order for the facility to call Resident #40's surgeon's office on 05/10/23 to set up a follow-up appointment as soon as possible. The order did not specify if the appointment needed to be in-person or via telehealth appointment. There were no other orders to reflect an actual appointment date had been set with the surgeon either via telehealth visit or in-person office visit for Resident #40 through 05/26/23. Review of the facility document provided to the surveyor by Medical Records (MR) #310 revealed MR #310 kept a calendar of medical appointments scheduled for residents at the facility. On this calendar she had written the cost to transport Resident #40 by ambulance would be a rate of $742.00. An appointment was scheduled on 05/18/23 at 9:15 A.M. then was cancelled by the facility. The appointment was moved to 06/08/23 with notes on the calendar reflecting the facility was trying to make a telehealth appointment due to the expense of transportation by ambulance. Review of progress notes dated 05/09/23 to 05/26/23 revealed no evidence the facility had asked Resident #40 or her family if they still wanted to proceed with the ambulance ride to the follow-up appointment on 05/18/23 with the surgeon despite the out-of-pocket cost nor were any alternative options for transportation or a telehealth option documented as discussed with the resident or her family. Review of nurse practitioner visit notes dated 05/11/23 and 05/25/23 and authored by Nurse Practitioner (NP) #329 revealed Resident #40 had a surgical incision on her back with sutures (a row of stitches holding a surgical wound together) and the surgeon would need to give orders regarding the status of the sutures. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 365580 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 365580 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/01/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shepherd of the Valley-Boardman 7148 West Blvd Youngstown, OH 44512 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)