Health inspection·November 12, 2024

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, medical record review, and review of the facility policy, the facility failed to ensure appropriate hand hygiene was performed during medication administration for Residents #21 and #44 and failed to ensure appropriate identification of resident transmission-based precautions status for Resident #44. This affected two residents (#21 and #44) of three residents who were observed during medication administration and had the potential to affect all 41 residents resining in the facility. Residents Affected - Few Findings include: 1. Review of the medical record for Resident #21revealed an initial admission date of 08/10/24 and a re-entry date of 11/06/24. Diagnoses included acute and chronic respiratory failure with hypoxia, active COVID-19 infection upon initial admission, chronic obstructive pulmonary disease (COPD), asthma, and presence of a cardiac pacemaker. Review of the most recent comprehensive Minimum Data Set (MDS) assessment completed on 09/07/24 revealed Resident #21 had intact cognition. High-risk medications included antidepressants, antibiotics, and antiplatelets. Review of the physician orders revealed an order dated 11/07/24 for Symbicort Inhalation Aerosol 160-4.5 micrograms per actuation (mcg/act)(Budesonide-Formoterol Fumarate Dihydrate), two puffs inhaled orally one time a day related to COPD. Observation on 11/12/24 from 8:40 A.M. to 8:43 A.M. revealed Licensed Practical Nurse (LPN) #331 completed medication administration for Resident #29 and exited Resident #29's room without performing hand hygiene. During the observation, LPN #331 proceeded to open the drawer to the medication cart, remove an inhaler labeled for Resident #21, used her laptop to document medication administration for Resident #29, poured water in a cup, and brought the cup of water, empty cup, and inhaler into the room of Resident #21 without performing hand hygiene. At 8:43 A.M., LPN #331 administered one puff of Symbicort Inhalation Aerosol (the first of the two ordered puffs was administered prior to the administration of Resident #21's medications), then assisted Resident #21 in taking water into his mouth by cup and instructed him to rinse and spit in the empty cup she held to his mouth. No hand hygiene was performed before or after administration of Resident #21's inhalation medication. Interview on 11/12/24 at 9:00 A.M. with LPN #331 confirmed she had not performed hand hygiene between administering medications to Resident #29 and Resident #21, and hand hygiene should be performed between providing medications to each resident. Review of the facility policy titled Medication Administration, last revised 06/18/24, revealed (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 11/12/2024 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)