Health inspection·September 18, 2025

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of the medical record, interview with staff, and review of the facility policy, the facility failed to ensure Resident #1 was shaved per his preferences. This affected one resident (Resident #1) of two reviewed for activities of daily living.Findings Include:Review of the medical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included acute respiratory failure, pneumonia, retention of urine, acute cough, radiculopathy, hypertension, glaucoma, heart failure, atherosclerotic heart disease, hyperlipidemia, and chronic kidney disease.Review of the physician's orders revealed Resident #1 had an order for Plavix (blood thinner) 10 milligrams once daily dated 09/04/25.Review of the plan of care dated 09/04/25 revealed Resident #1 was on Plavix and was at risk for bleeding and irregular clotting. Interventions included to use caution when shaving. The care plan further revealed the resident had an ADL self-care performance deficit related to disease processes with interventions for set up and supervision of one staff for personal hygiene and for staff to understand the residents daily preferences and abilities could fluctuate. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had intact cognition.Review of the medical record revealed no documented evidence that Resident #1 was shaved during his time at the facility. On 09/15/25 at 1:49 P.M. an interview with Resident #1 revealed he wanted to be shaved, but nobody would shave him because he was on a blood thinner. He stated he felt bad that he had not been shaved. Observation at this time revealed his beard was approximately a quarter inch long.On 09/15/25 at 2:00 P.M. an interview with Licensed Practical Nurse #125 verified Resident #1 needed shaved. She stated he was on a blood thinner, so a nurse had to shave him. On 09/16/25 at 8:49 A.M. an interview with Resident #1 revealed he was thankful to be shaved and he felt so much better. Review of the facility policy titled, Shaving the Resident, dated 08/15/12 revealed the policy was to promote cleanliness and to provide skin care safety. Residents Affected - Few 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: 366453 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 366453 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/18/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shepherd of the Valley Poland 301 West Western Reserve Road Poland, OH 44514 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)