Inspection Reports for
Shepherd of the Hills Living Center
996 STATE HIGHWAY 248, BRANSON, MO, 65616-8154
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
5.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
5% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
78 residents
Based on a November 2025 inspection.
Occupancy over time
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 1
Date: Nov 20, 2025
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to obtain a physician order, include in the care plan, and monitor the use of a cardiac life vest for one resident.
Complaint Details
Complaint #2633767 regarding failure to properly manage a resident's cardiac life vest including lack of physician orders, care plan inclusion, and staff education.
Findings
The facility failed to obtain and document physician orders related to the resident's cardiac life vest, did not include the life vest in the resident's care plan, and nursing staff lacked education and training on the use and monitoring of the cardiac life vest. Several staff members interviewed were unaware or had no experience with cardiac life vests.
Deficiencies (1)
Failure to obtain a physician order, include in the care plan, and monitor the use of a cardiac life vest for one resident.
Report Facts
Residents in sample size: 7
Facility census: 78
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse E | Licensed Practical Nurse | Interviewed regarding lack of experience and training with cardiac life vests |
| Certified Nurse Assistant A | Certified Nurse Assistant | Interviewed about awareness of cardiac life vest use in facility |
| LPN B | Licensed Practical Nurse | Responsible for physician orders and clinical admission assessment; interviewed about cardiac life vest procedures |
| Registered Nurse C | Registered Nurse | Interviewed about lack of knowledge and experience with cardiac life vests |
| LPN D | Licensed Practical Nurse | Interviewed about facility admission policies and care for residents with cardiac life vests |
| Certified Medication Technician F | Certified Medication Technician | Interviewed about resident's use of a brace and care plan inclusion |
| MDS Coordinator | Interviewed about care plan creation and lack of cardiac life vest documentation | |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed about resident's use of cardiac life vest and facility procedures |
| Director of Nursing | Director of Nursing | Interviewed about lack of physician orders and staff education on cardiac life vests |
| Administrator | Administrator | Interviewed about resident admission without life vest orders and delivery of life vest |
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 3
Date: Jul 29, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure proper pharmaceutical services, specifically the management and destruction of controlled substance medications.
Complaint Details
Complaint number 2560530 triggered the investigation. The complaint involved concerns about the management and destruction of controlled substance medications.
Findings
The facility failed to maintain an accurate system of records for receipt and disposition of controlled drugs, ensure drug records were in order, and maintain accountability for controlled substances pending destruction. There were 159 cards of unused controlled substance medications stored in locked cabinets that had not been destroyed in a timely manner, posing minimal harm or potential for actual harm to residents.
Deficiencies (3)
Failed to ensure pharmacy services established a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation.
Failed to ensure drug records were in order and an account of all controlled drugs was maintained and periodically reconciled.
Failed to have a system of accountability for 159 cards of unused controlled substance medications pending destruction stored in locked cabinets.
Report Facts
Residents affected: 73
Medication cards pending destruction: 159
Facility census: 69
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) A | Interviewed regarding medication destruction procedures and discharge medication handling. | |
| Certified Medication Technician (CMT) B | Interviewed about narcotics handling and destruction schedule. | |
| Registered Nurse (RN) C | Interviewed about narcotics disposition and destruction process. | |
| Social Service Director (SSD) | Interviewed about discharge process and medication handling. | |
| Director of Nursing (DON) | Interviewed about controlled substance destruction procedures and storage. | |
| Assistant Director of Nursing (ADON) | Mentioned in relation to medication destruction responsibilities and storage. | |
| Administrator | Interviewed regarding narcotics handling and destruction schedule. |
Inspection Report
Routine
Deficiencies: 8
Date: Mar 21, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication self-administration, grievance resolution, activities of daily living assistance, accident hazards, dialysis care, drug regimen review, medication storage, and resident privacy.
Findings
The facility was found deficient in multiple areas including failure to assess residents for safe self-administration of medications, incomplete grievance resolution, inadequate assistance with personal hygiene and bathing, unsafe medication supervision and storage practices, failure to investigate a fall, incomplete monitoring of dialysis access, delayed physician response to pharmacist medication recommendations, and lack of privacy curtains in semi-private rooms.
Deficiencies (8)
Failed to ensure staff assessed resident for safe self-administration of medications before allowing self-administration.
Failed to resolve and document full resolution of a resident grievance regarding missing funds.
Failed to provide nail care, shaving, and scheduled bathing assistance to residents as per care plans and facility policies.
Failed to ensure nursing staff supervised residents during medication administration and failed to investigate a fall incident.
Failed to monitor and document bruit and thrill of resident's AV shunt for dialysis as required.
Failed to ensure physician reviewed and acted upon pharmacist medication irregularity recommendations in a timely manner.
Failed to ensure expired medication was not stored in resident's room.
Failed to provide privacy curtains between residents in semi-private rooms.
Report Facts
Residents reviewed for medication self-administration: 2
Residents reviewed for grievances: 2
Residents reviewed for ADL care: 2
Residents reviewed for accidents and hazards: 9
Residents reviewed for falls: 3
Residents reviewed for dialysis services: 1
Residents reviewed for unnecessary medications: 5
Semi-private rooms in facility: 48
Pharmacist recommendations not acted upon: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Medication Technician #6 | Acknowledged resident administered inhaler independently without assessment | |
| Director of Nursing | Director of Nursing (DON) | Provided information on medication self-administration assessments and grievance investigation |
| Certified Nurse Assistant #13 | CNA | Reported on resident grooming and shower assistance |
| Licensed Practical Nurse #16 | LPN | Discussed resident shower refusals and grooming needs |
| Registered Nurse #12 | RN | Discussed shower sheet completion and grooming care |
| Certified Medication Technician #5 | CMT | Left medications unattended in resident's room |
| Licensed Practical Nurse #7 | LPN | Observed medications left unattended and described fall incident handling |
| Social Worker | SW | Oversaw grievance investigation |
| Administrator | Administrator | Provided expectations on resident grooming and medication administration |
| Pharmacy Consultant | Discussed medication regimen reviews and communication with facility | |
| Medical Director | Medical Director | Discussed review of pharmacy recommendations |
| Licensed Practical Nurse #1 | LPN | Discussed dialysis AV shunt monitoring |
| Licensed Practical Nurse #2 | LPN | Discussed dialysis AV shunt monitoring |
| Certified Nurse Assistant #9 | CNA | Commented on missing privacy curtain |
| Licensed Practical Nurse #8 | LPN | Commented on missing privacy curtain |
| Environmental Supervisor | Environmental Supervisor | Explained privacy curtain removal and replacement issues |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 21, 2024
Visit Reason
The inspection was conducted to investigate complaints related to medication administration practices and fall incident investigations at Shepherd of the Hills Living Center.
Complaint Details
The complaint investigation revealed issues with medication supervision for four residents and failure to investigate a fall incident for one resident. The fall was not documented or assessed properly, and staff did not follow facility protocols for fall investigations.
Findings
The facility failed to ensure nursing staff supervised residents during medication administration, leaving medications unattended in residents' rooms for multiple residents. Additionally, the facility failed to identify and investigate a fall incident for one resident, not following proper fall assessment and documentation procedures.
Deficiencies (2)
Failure to ensure nursing staff supervised residents during medication administration and prevent medications from being left unattended in residents' rooms.
Failure to identify and investigate a fall incident for a resident, including lack of documentation and assessment.
Report Facts
Residents reviewed for accidents and hazards: 9
Residents with medication supervision issues: 4
Residents reviewed for falls: 3
Resident with uninvestigated fall: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Interviewed regarding medication administration and leaving medications unattended |
| Certified Medication Technician #5 | Certified Medication Technician | Interviewed about leaving medications in resident's room |
| Licensed Practical Nurse #7 | Licensed Practical Nurse | Observed medications left unattended and discussed fall incident procedures |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Discussed medication supervision challenges |
| Certified Medication Technician #3 | Certified Medication Technician | Discussed medication administration practices |
| Director of Nursing | Director of Nursing | Provided expectations for medication administration and fall investigation procedures |
| Administrator | Administrator | Discussed expectations for staff regarding medication administration and fall investigations |
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 1
Date: Nov 20, 2023
Visit Reason
The inspection was conducted following a complaint investigation related to a resident fall incident where staff failed to place foot rests on the resident's wheelchair, resulting in the resident falling and sustaining injuries.
Complaint Details
Complaint #MO00227438 investigated the fall incident involving Resident #1 due to staff not placing foot rests on the wheelchair, resulting in injury.
Findings
The facility failed to provide adequate protective oversight for a resident, leading to a fall from a wheelchair without foot rests, causing a facial laceration and broken nose. The investigation revealed staff education gaps and failure to follow wheelchair positioning protocols despite occupational therapy training.
Deficiencies (1)
Failure to provide protective oversight by not placing foot rests on resident's wheelchair, resulting in fall and injury.
Report Facts
Facility census: 78
Pain intensity scale: 5
Length of scar: 4.5
Date of original admission: Jun 13, 2022
Date of re-admission: Nov 11, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN B | Registered Nurse | Described fall incident and emergency response |
| CNA A | Certified Nurse Assistant | Reported forgetting to place footrests on wheelchair |
| OT C | Occupational Therapist | Provided education on wheelchair positioning and fall prevention |
| CNA D | Certified Nurse Assistant | Responsible for direct care on day of fall, failed to place footrests |
| CNA F | Certified Nurse Assistant | Witnessed fall, noted absence of footrests |
| RN E | MDS Coordinator | Updated resident care plan post-fall |
| DON | Director of Nursing | Discussed investigation findings and care plan updates |
Inspection Report
Complaint Investigation
Census: 79
Deficiencies: 1
Date: Sep 29, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to timely report an allegation of possible abuse involving a resident's penile prosthesis.
Complaint Details
The complaint involved an allegation by Resident #1 that approximately a year and a half ago an aide asked to sit on his penile prosthesis, which has not worked since. The Medical Director did not report this allegation to authorities. The facility did not self-report the allegation. Interviews with staff confirmed the requirement to report all abuse allegations immediately and within two hours to the State Survey Agency.
Findings
The facility failed to ensure that an allegation of possible sexual abuse reported by a resident was immediately reported to the facility manager and within two hours to the State Survey Agency. The Medical Director did not report the allegation because he did not believe it was abuse, contrary to facility policy and regulatory requirements.
Deficiencies (1)
Failure to timely report suspected abuse to the facility manager and State Survey Agency as required by policy and regulation.
Report Facts
Facility census: 79
Resident admission date: Jan 22, 2021
Resident MDS assessment date: Sep 17, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Medical Director | Did not report allegation of abuse as required | |
| Director of Nursing | DON | Spoke with resident about abuse allegation and confirmed Medical Director's failure to report |
| Certified Nurse Aide B | CNA | Stated all allegations of abuse must be reported immediately and within two hours |
| Certified Nurse Aide C | CNA | Stated all allegations of abuse must be reported immediately and within two hours |
Inspection Report
Routine
Census: 77
Deficiencies: 10
Date: Jul 28, 2022
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including abuse and neglect hotline posting, Medicare/Medicaid contact information posting, notification of Medicare non-coverage, transfer/discharge notification, bed hold policy notification, baseline care plan completion, side rail use, medication administration, food service, and infection control.
Findings
The facility failed to properly post abuse and neglect hotline and Medicare/Medicaid contact information, failed to provide Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) or Notice of Medicare Non-Coverage (NOMNC) to a resident, failed to notify residents and representatives in writing of hospital transfers and bed hold policies, failed to complete baseline care plans within 48 hours for two residents, failed to properly assess and document side rail use for four residents, had medication administration errors related to insulin pen priming for two residents, failed to serve meals with correct portion sizes, failed to properly store dry food and enforce hair covering policies in the kitchen, and failed to complete and document employee tuberculosis screening tests for six staff members.
Deficiencies (10)
Failed to post abuse and neglect hotline and Medicare/Medicaid contact information accessibly.
Failed to provide Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) or Notice of Medicare Non-Coverage (NOMNC) to a resident at Medicare Part A discharge.
Failed to notify residents, representatives, and ombudsman in writing of hospital transfers and failed to provide transfer/discharge letters for four residents.
Failed to provide written notification of bed hold policy to residents and representatives at time of hospital transfer for four residents.
Failed to complete baseline care plans within 48 hours of admission for two residents.
Failed to assess, obtain consent, document risk/benefit, and measure bed rails for side rail use for four residents.
Medication administration errors: staff failed to prime insulin pens prior to administration for two residents, contrary to manufacturer instructions.
Failed to serve meals with correct portion sizes according to approved menu and recipes.
Failed to properly store dry food items in sealed containers and failed to wear proper hair coverings in the kitchen and serving areas.
Failed to complete and document employee tuberculosis screening tests properly for six staff members, including failure to document reading of tests and second step testing.
Report Facts
Facility census: 77
Medication error rate: 6.45
Insulin dose: 4
Insulin dose: 30
Resident glucose level: 295
Resident glucose level: 146
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN G | Licensed Practical Nurse | Administered insulin without priming pen |
| RN H | Registered Nurse | Administered insulin glargine without priming pen |
| DA A | Dietary Aide | Interviewed about dry food storage practices |
| DA L | Dietary Aide | Observed working in kitchen and serving area without hair net |
| CNA C | Certified Nurse Aide | Interviewed about abuse hotline posting and side rail use |
| Director of Nursing | Director of Nursing | Interviewed about abuse hotline posting, side rail use, medication administration, and TB screening |
| Administrator | Administrator | Interviewed about abuse hotline posting, side rail use, medication administration, food service, and TB screening |
| Social Service Director | Social Service Director | Interviewed about notification of hospital transfers and bed hold policy |
Inspection Report
Routine
Census: 78
Deficiencies: 3
Date: Sep 3, 2019
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to pressure ulcer care, resident safety in smoking areas, and food service sanitation at Shepherd of the Hills Living Center.
Findings
The facility failed to properly assess, document, and treat newly identified pressure ulcers for two residents, failed to ensure oxygen tanks were removed from residents in the designated smoking area, and failed to properly clean and maintain the ice machine used for food service.
Deficiencies (3)
Failed to perform initial assessment, document, notify physician, and obtain treatment orders for newly identified pressure ulcers and failed to perform treatment using appropriate infection control techniques.
Failed to ensure residents' safety by not removing oxygen tanks from residents while in the designated smoking area.
Failed to ensure food items were stored in accordance with professional standards when the ice machine was not properly cleaned and maintained.
Report Facts
Residents affected: 18
Residents affected: 78
Oxygen flow rate: 5
Oxygen flow rate: 3
Oxygen flow rate: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Performed wound care treatment and failed to document initial assessment or notify physician for new pressure ulcers |
| LPN B | Licensed Practical Nurse | Performed wound treatment and described proper procedures for new pressure ulcers |
| ADON | Assistant Director of Nursing | Facility wound nurse who performed wound assessments and described required procedures |
| CNA C | Certified Nursing Assistant | Described reporting procedures for new pressure ulcers |
| CNA D | Certified Nursing Assistant | Described reporting procedures for new pressure ulcers and oxygen safety |
| LPN G | Licensed Practical Nurse | Described wound care procedures and smoking safety supervision |
| Dietary Manager | Dietary Manager | Described ice machine cleaning responsibilities |
| Maintenance Supervisor | Maintenance Supervisor | Described ice machine cleaning responsibilities and lack of documentation |
| Director of Nursing | Director of Nursing | Described wound care procedures, smoking safety policies, and staff training |
| Dietary [NAME] E | Dietary Staff | Observed removing oxygen nasal cannula from resident in smoking area |
Viewing
Loading inspection reports...
