Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Shepherd Of The Valley Poland during CMS and state inspections, most recent first.
A resident with CHF, bipolar disorder, and knee pain was discharged with new orders for doxycycline and prednisone, and the nurse reviewed the discharge instructions and meds with the resident and spouse. However, the RN confirmed she did not call the prescriptions to the pharmacy to ensure the resident could obtain the ordered discharge meds, and the NP stated nursing staff normally handled pharmacy calls for home meds.
A resident with intact cognition and on a blood thinner was not shaved according to his preferences, as staff avoided shaving him due to his medication, despite care plan instructions for caution and supervision. The resident expressed dissatisfaction, and observation confirmed he was unshaven, contrary to facility policy.
A resident with multiple medical conditions requiring oxygen therapy was observed to be short of breath, with their portable oxygen tank found in a non-functional state and oxygen saturation at 85%. An LPN intervened and restored function to the tank, resulting in a slight improvement in oxygen saturation. The facility did not follow its own guidelines for safe oxygen administration, leading to a failure in providing appropriate respiratory care.
A resident with chronic kidney disease experienced an acute change in condition, including nausea, vomiting, and diarrhea, which were not adequately treated by the facility. Despite standing orders for medications, these were not administered, and the resident's condition deteriorated, leading to hospitalization and eventual death. Interviews revealed a lack of communication and timely intervention by the facility's staff.
The facility failed to notify physicians of significant changes in two residents' conditions, including weight gain, decreased meal intake, and low blood pressure. Despite orders to inform physicians of such changes, there was no evidence of communication. The Medical Director confirmed being unaware of these issues, indicating non-compliance with the facility's notification policy.
The facility failed to establish measurable parameters for as-needed pain medications, affecting three residents. A resident admitted for knee replacement received inconsistent pain medication due to undefined pain severity levels. Another resident with a fractured femur also experienced inconsistent pain management, confirmed by the DON. A third resident with multiple diagnoses received pain medications without clear guidelines, leading to inconsistent administration. The facility's pain management policy lacked specific numerical values for pain levels, contributing to the issue.
Discharge medications not ensured for resident
Penalty
Summary
The facility failed to ensure Resident #32 had appropriate supports in place for discharge, including discharge medications. Resident #32 was admitted with diagnoses including chronic systolic congestive heart failure, bipolar disorder, and pain in the right knee, and the admission MDS indicated intact cognition. On 01/09/26, the nurse practitioner entered new discharge orders for doxycycline 100 mg by mouth twice daily for 10 days and prednisone 20 mg by mouth daily for 10 days, and documented that the resident was okay for discharge and was notified of the new orders. On 01/10/26, the nurse documented reviewing the discharge instructions and medications with the resident and the resident's husband, providing the discharge folder, and sending all belongings with the resident as the resident left by wheelchair in a private vehicle. The discharge plan and needs assessment also documented that medications were reviewed with the resident/family. During interview, the RN confirmed she discharged the resident and reviewed the medications but did not call the prescriptions to the pharmacy to ensure the resident could obtain the ordered discharge medications, stating she thought another nurse may have done so. The NP stated she only wrote the orders and that nursing staff always called the pharmacy to order home medications. The facility policy stated residents discharging from the facility are to receive adequate preparation and information to make the transfer as safe and orderly as possible.
Failure to Provide Shaving per Resident Preference While on Anticoagulant
Penalty
Summary
The facility failed to ensure that a resident was shaved according to his preferences, despite his ability to express his wishes and having intact cognition. The resident, who had multiple medical diagnoses including acute respiratory failure, heart failure, and chronic kidney disease, was admitted with an order for Plavix, a blood thinner, which placed him at risk for bleeding. The care plan specified that caution should be used when shaving and that staff should provide setup and supervision for personal hygiene, taking into account the resident's daily preferences and fluctuating abilities. During the resident's stay, there was no documented evidence that he was shaved, and interviews revealed that staff refrained from shaving him due to his anticoagulant therapy, stating that only a nurse could perform the task. The resident expressed feeling bad about not being shaved and indicated that his preference was not being met. Observation confirmed that his beard had grown to approximately a quarter inch. The facility's policy on shaving emphasized cleanliness and skin care safety, but this was not followed in the resident's case.
Failure to Ensure Proper Functioning of Portable Oxygen Tank
Penalty
Summary
The facility failed to ensure that a portable oxygen tank was functioning properly for a resident who required oxygen therapy. Observation revealed that the resident, who had a history of acute respiratory failure, pneumonia, heart failure, and other significant medical conditions, was short of breath while speaking. The resident's nasal cannula was attached to a portable oxygen tank, but the tank's dial was in the red area, indicating it was either empty or turned off. At this time, the resident's oxygen saturation was measured at 85%, which is below the physician-ordered threshold of 92%. A Licensed Practical Nurse (LPN) checked the oxygen tank, pressed a button, and the gauge moved, after which the resident's oxygen saturation increased to 89%. The LPN confirmed that the oxygen tank was not working when the resident was attempting to use it to maintain adequate oxygen saturation. Review of the facility's policy on oxygen administration indicated that guidelines were in place for safe oxygen use, but these were not followed in this instance, resulting in the resident not receiving appropriate respiratory care.
Failure to Monitor and Treat Acute Change in Condition
Penalty
Summary
The facility failed to adequately monitor and provide timely and necessary care for a resident with chronic Stage 3 kidney disease who experienced an acute change in condition. The resident exhibited symptoms such as nausea, vomiting, diarrhea, fatigue, and decreased appetite, which were not adequately addressed. Despite the presence of standing orders for medications like Imodium and Phenergan, these were not administered to manage the resident's symptoms. The resident's condition deteriorated, leading to hypotension, poor oral intake, and further gastrointestinal issues. The resident was eventually transported to the emergency room and admitted to the intensive care unit with diagnoses including sepsis, acute kidney injury, and dehydration. The facility's records indicated a lack of timely intervention and communication with the physician regarding the resident's worsening condition. The resident's meal intake was significantly reduced, and there was no evidence of appropriate medication administration to address the symptoms. The facility's staff, including nurses and nurse practitioners, failed to act on alerts and standing orders that could have mitigated the resident's condition. Interviews with facility staff revealed a lack of awareness and communication regarding the resident's condition and care needs. The resident's daughter reported concerns about the resident's care, including instances of slurred speech and inadequate response to the resident's symptoms. The facility's policy on notifying physicians of changes in resident conditions was not followed, contributing to the resident's decline and eventual death from multiple organ failure and related complications.
Failure to Notify Physician of Resident Condition Changes
Penalty
Summary
The facility failed to notify the physician of significant changes in the conditions of two residents, leading to a deficiency. Resident #5, who was admitted with multiple diagnoses including heart failure and malnutrition, experienced a weight gain of 3.2 pounds in one day. Despite physician orders to notify them of any weight gain exceeding two pounds in a day, there was no evidence that the physician was informed of this change. The Director of Nursing acknowledged the oversight, noting that the weight gain was recorded but not communicated as required. Resident #27, admitted for rehabilitative services following knee replacement surgery, also experienced a lack of proper notification to the physician. The resident had a history of chronic kidney disease and hypertension, among other conditions. Despite a significant decrease in meal intake and episodes of diarrhea, there was no evidence that the physician was notified of these changes. Additionally, the resident's anti-hypertensive medications were held due to low blood pressure, yet the physician was not informed of this decision. The Medical Director confirmed that they were unaware of the decreased meal intake and the holding of medications. The facility's policy on notifying physicians of changes in resident conditions was not followed, as evidenced by the lack of communication regarding the residents' weight gain, meal intake, and medication adjustments. This deficiency was identified during a complaint investigation, highlighting the facility's non-compliance with its own notification policy.
Lack of Defined Pain Management Parameters
Penalty
Summary
The facility failed to establish measurable parameters for the administration of as-needed pain medications, resulting in the potential for residents to receive unnecessary medications. This deficiency was identified through a review of medical records and interviews with staff, affecting three residents. Resident #27, admitted for rehabilitative services following a knee replacement, was administered both acetaminophen and oxycodone without defined parameters for what constituted mild, moderate, or severe pain. This led to inconsistent administration of pain medication based on subjective nursing judgment rather than standardized criteria. Similarly, Resident #5, admitted with a fractured femur and other medical conditions, received acetaminophen and oxycodone for varying pain levels without clear guidelines. The Director of Nursing confirmed that there were no established parameters for determining when to administer each type of medication, resulting in inconsistent pain management practices. The facility's pain management policy did not specify numerical values for pain levels, contributing to the inconsistency. Resident #9, with multiple diagnoses including a fractured femur and fibromyalgia, also received pain medications without defined parameters for pain severity. The resident's medication administration record showed the use of methocarbamol, oxycodone, acetaminophen, and Ultram for a wide range of pain levels, including instances where narcotics were administered despite a reported pain level of zero. The Director of Nursing verified the lack of parameters and the inconsistent administration of pain medications, highlighting a systemic issue in the facility's pain management practices.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Poland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Caprice Health Care Center | 0.4 mi | ★★★★★ | 5 | 0 |
| Briarfield Place | 0.6 mi | ★★★★★ | 3 | 0 |
| Willow Woods Rehabilitation And Nursing | 0.7 mi | ★★★★★ | 10 | 0 |
| Aventura At Assumption Village | 0.9 mi | ★★★★★ | 19 | 1 |
| Greenbriar Center | 2.2 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.