Inspection Reports for
Shepherd of the Hills Living Center
996 STATE HIGHWAY 248, BRANSON, MO, 65616-8154
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
11 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
100% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
40
30
20
10
0
Occupancy
Latest occupancy rate
78% occupied
Based on a November 2025 inspection.
Occupancy rate 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
Plan of Correction
Census: 71
Deficiencies: 2
Date: Mar 25, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulations regarding abuse, neglect, and misappropriation policies, specifically focusing on employment disqualification list (EDL) and Certified Nurse Aide (CNA) registry checks for new hires.
Findings
The facility failed to implement policies to prevent abuse, neglect, or misappropriation of residents by not documenting employment disqualification list and CNA registry checks for several staff members. Personnel records for three staff lacked required CNA registry checks upon hire and prior to resident contact.
Deficiencies (2)
F607: The facility failed to develop and implement policies to prevent abuse, neglect, and misappropriation by not documenting employment disqualification list and CNA registry checks for three staff members. Personnel records showed missing CNA registry checks upon hire and prior to resident contact.
A8023: The facility did not meet the requirement to develop and implement policies prohibiting mistreatment, neglect, and abuse of residents, as evidenced by the F607 deficiency. This violation was classified as Class II.
Report Facts
Facility census: 71
Staff with missing documentation: 3
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
Recertification Survey Complaint Investigation
Deficiencies: 8
Date: Mar 21, 2024
Visit Reason
A Recertification Survey and Complaint Survey was conducted from 03/18/2024 to 03/21/2024 to assess compliance with federal regulations for long term care facilities.
Complaint Details
The survey included a complaint investigation component addressing grievances filed by residents, including a missing money grievance and medication administration concerns.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, with multiple deficiencies cited related to resident self-administration of medications, grievance resolution, activities of daily living care, accident hazards, dialysis care, drug regimen review, medication storage, and privacy.
Deficiencies (8)
F-554 Resident Self-Admin Meds-Clinically Appropriate. The facility failed to ensure staff assessed one resident for safe self-administration of medications before allowing self-administration.
F-585 Grievances. The facility failed to resolve a grievance and document full resolution for one resident of two reviewed for grievances.
F-677 ADL Care Provided for Dependent Residents. The facility failed to ensure two residents received adequate grooming and personal hygiene care including nail care and shaving.
F-689 Free of Accident Hazards/Supervision/Devices. The facility failed to ensure nursing staff supervised residents during medication administration and failed to investigate a fall for one resident.
F-698 Dialysis. The facility failed to monitor and document the bruit and thrill of a resident's AV shunt for dialysis.
F-756 Drug Regimen Review, Report Irregular, Act On. The facility failed to ensure timely pharmacist review and reporting of medication irregularities for one resident.
F-761 Label/Store Drugs and Biologicals. The facility failed to ensure expired medication was not stored in a resident's room.
F-914 Bedrooms Assure Full Visual Privacy. The facility failed to ensure privacy curtains were in place between two residents sharing a semi-private room.
Report Facts
Number of residents reviewed for self-administration: 2
Number of residents reviewed for grievances: 2
Number of residents reviewed for ADL care: 2
Number of residents reviewed for accident hazards: 9
Number of residents reviewed for medication storage: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Named in medication administration and grievance investigation findings. |
| Certified Medication Technician #6 | Certified Medication Technician | Interviewed regarding resident medication self-administration. |
| Social Worker | Social Worker (SW) | Facility grievance coordinator involved in grievance investigation. |
| Certified Nurse Assistant #13 | Certified Nurse Assistant (CNA) | Interviewed regarding resident grooming and shower assistance. |
| Licensed Practical Nurse #16 | Licensed Practical Nurse (LPN) | Interviewed regarding resident grooming and shower assistance. |
| Certified Nurse Assistant #15 | Certified Nurse Assistant (CNA) | Interviewed regarding resident grooming and shower assistance. |
| Certified Nurse Assistant #14 | Certified Nurse Assistant (CNA) | Interviewed regarding resident grooming and shower assistance. |
| Licensed Practical Nurse #4 | Licensed Practical Nurse (LPN) | Interviewed regarding medication administration and resident safety. |
| Certified Medication Technician #5 | Certified Medication Technician (CMT) | Interviewed regarding medication administration and safety. |
| Licensed Practical Nurse #7 | Licensed Practical Nurse (LPN) | Interviewed regarding medication administration and resident falls. |
| Administrator | Administrator | Interviewed regarding facility standards and grievance resolution. |
| Pharmacy Consultant | Pharmacy Consultant | Interviewed regarding drug regimen review and medication irregularities. |
| Medical Director | Medical Director | Interviewed regarding pharmacy recommendations and medication reviews. |
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: 2
Date: Nov 20, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding a resident fall and the facility's failure to provide adequate protective oversight and supervision to prevent accidents.
Complaint Details
Complaint #MO00227438 was investigated. The complaint was substantiated as the facility failed to provide adequate supervision and protective oversight to a resident, leading to a fall and injury.
Findings
The facility failed to provide adequate supervision and protective oversight to a resident using a wheelchair, resulting in a fall that caused a facial laceration and broken nose. The investigation revealed multiple failures in staff adherence to care plans and proper wheelchair positioning.
Deficiencies (2)
F689 Free of Accident Hazards/Supervision/Devices CFR(s): 483.25(d)(1)(2) The facility failed to provide protective oversight to one resident, resulting in a fall from a wheelchair causing facial laceration and broken nose. The resident's care plan and risk assessments indicated a high fall risk and need for supervision.
A4074 19 CSR 30-85.042(65) Protective Oversight, Voluntary Leave The facility did not meet the requirement for protective oversight and supervision for residents on voluntary leave, as evidenced by the referenced F689 deficiency.
Report Facts
Facility census: 78
Dates related to resident events: Multiple dates from 06/13/22 to 11/20/23 related to resident admission, falls, and care plan updates
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Named in relation to education and investigation of resident fall and wheelchair positioning |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Named in relation to education regarding resident's proper sitting posture and wheelchair configuration |
| Registered Nurse B | Registered Nurse (RN) | Interviewed regarding resident fall and response |
| Occupational Therapist C | Occupational Therapist (OT) | Interviewed regarding resident fall, wheelchair positioning, and staff education |
| MDS Coordinator RN E | MDS Coordinator (RN) | Interviewed regarding fall interventions and care plan updates |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding investigation of fall and care plan updates |
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
Plan of Correction
Census: 79
Deficiencies: 2
Date: Sep 29, 2023
Visit Reason
The inspection was conducted in response to allegations of abuse, neglect, exploitation, or mistreatment at Shepherd of the Hills Living Center.
Findings
The facility failed to report alleged violations of abuse immediately as required by regulation. The Medical Director did not report an allegation of possible abuse within the required timeframe, and the facility did not meet the mandated reporting requirements.
Deficiencies (2)
F609: The facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, including injuries of unknown source and misappropriation of resident property.
A8023: The facility did not develop and implement written policies prohibiting mistreatment, neglect, abuse, and misappropriation of resident property, and failed to require reports to the department for any resident or vulnerable person.
Report Facts
Facility census: 79
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lauren Nemes | Signed the statement of deficiencies and plan of correction | |
| Medical Director | Did not report allegation of abuse within required timeframe | |
| Director of Nursing | DON | Discussed abuse allegations with resident and was involved in reporting process |
| Certified Nurse Aide B | CNA | Stated all allegations of abuse must be reported |
| Certified Nurse Aide C | CNA | Stated all allegations of abuse must be reported |
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
Life Safety
Census: 77
Capacity: 100
Deficiencies: 2
Date: Jul 28, 2022
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code and related fire safety regulations, focusing on sprinkler system maintenance and smoke barrier doors.
Findings
The facility failed to keep sprinkler heads free from debris and maintain the smoke resistive properties of smoke barrier doors, resulting in obstructions and gaps that could affect fire safety. Observations and interviews confirmed these deficiencies potentially impacting residents, staff, and visitors.
Deficiencies (2)
K353 Sprinkler System - The facility failed to keep sprinkler heads free from debris, obstructing spray patterns above multiple resident rooms. This failure could affect all residents, staff, and visitors in the event of a fire.
K374 Smoke Barrier Doors - The facility failed to maintain smoke barrier doors by allowing significant gaps and door latches that did not fully close, potentially allowing smoke to pass between compartments. This deficiency could affect all residents, staff, and visitors.
Report Facts
Facility capacity: 100
Census: 77
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding sprinkler head obstructions and smoke barrier door issues | |
| Administrator | Interviewed regarding sprinkler head obstructions and smoke barrier door issues | |
| Maintenance Supervisor/Designee | Responsible for removing debris and monitoring sprinkler heads and smoke barrier doors |
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
Complaint Investigation
Deficiencies: 0
Date: Jan 21, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted as a complaint investigation.
Complaint Details
No deficiencies were cited on this complaint investigation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19. No deficiencies were cited during this complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 5, 2021
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with relevant regulations and CDC recommended practices.
Complaint Details
No deficiencies were cited on this complaint investigation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19. No deficiencies were cited during this complaint investigation.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 20, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.
Complaint Details
No deficiencies were cited on this complaint investigation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 (b)(6) and CMS and CDC recommended practices for COVID-19. No deficiencies were cited during this complaint investigation.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Nov 24, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted to assess the facility's compliance with relevant CMS and CDC guidelines.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Aug 19, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control survey was conducted as a complaint investigation to assess compliance with CMS and CDC recommended practices related to COVID-19.
Complaint Details
This was a complaint investigation related to COVID-19 focused emergency preparedness and infection control. No deficiencies were cited.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended infection control practices. No deficiencies were cited during this complaint investigation.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 30, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted on 07/30/2020 to assess compliance with relevant regulations and CDC recommended practices.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Report Facts
Number of rule noncompliances: 0
Inspection Report
Routine
Deficiencies: 0
Date: Jun 10, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess the facility's compliance with CMS and CDC recommended practices for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Annual Inspection
Census: 78
Deficiencies: 6
Date: Sep 3, 2019
Visit Reason
The inspection was conducted as an annual survey to assess compliance with federal regulations related to resident care, safety, and facility operations at Shepherd of the Hills Living Center.
Findings
The facility was found deficient in multiple areas including pressure ulcer prevention and treatment, accident prevention related to oxygen tanks in the smoking area, and food safety practices. Deficiencies were documented with detailed observations, record reviews, and staff interviews.
Deficiencies (6)
F686: The facility failed to perform initial assessments, document treatment orders, and use appropriate infection control techniques for residents with pressure ulcers. Staff did not consistently document new pressure ulcers or notify physicians as required.
F689: The facility failed to ensure the resident environment was free of accident hazards by not removing oxygen tanks from the designated smoking area, risking resident safety.
F812: The facility failed to properly clean and maintain the ice machine, resulting in food safety risks.
A4073: The facility did not provide twenty-four hour protective oversight for residents on voluntary leave as required.
A4082: The facility failed to keep residents free from avoidable pressure sores by not providing adequate prevention and treatment.
A7015: The facility failed to protect food from contamination and maintain proper food safety temperatures.
Report Facts
Facility census: 78
Number of residents with pressure ulcers: 2
Number of residents with oxygen tanks in smoking area: 2
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Sep 3, 2019
Visit Reason
The inspection was conducted as an annual recertification and licensure inspection to verify compliance with life safety and state licensure requirements.
Findings
No emergency preparedness deficiencies or state licensure deficiencies were cited. The facility meets the applicable provisions of the 2012 edition of the Life Safety Code of the National Fire Protection Association.
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 |
Inspection Report
Life Safety
Census: 77
Capacity: 100
Deficiencies: 32
Date: Jul 31, 2018
Visit Reason
The inspection was a Life Safety Code survey to assess compliance with fire safety and emergency preparedness regulations at Shepherd of the Hills Living Center.
Findings
The facility failed to meet several Life Safety Code requirements including emergency preparedness planning, delayed egress locking systems, smoke barrier doors, corridor width maintenance, sprinkler system maintenance, electrical safety, and fire drills. Deficiencies had the potential to affect all residents, staff, and visitors.
Deficiencies (32)
E001 Emergency Program: The facility failed to provide an Emergency Operations Plan with complete facility-specific information.
K222 Egress Doors: The facility failed to assure delayed egress magnetic locking devices released properly, allowing one door to remain locked after pressure was applied.
K223 Doors with Self-Closing Devices: The facility allowed a kitchen door to remain propped open with a wooden block, compromising smoke barrier integrity.
K232 Aisle, Corridor, or Ramp Width: The facility failed to maintain corridor width by allowing 12 soiled linen cans to obstruct the exit path.
K271 Discharge from Exits: The facility failed to maintain level walking surfaces, allowing raised ridges between sidewalk sections.
K281 Illumination of Means of Egress: The facility failed to provide adequate continuous illumination for exit discharge areas during power outages and normal conditions.
K293 Exit Signage: The facility failed to place exit signs at required locations, causing potential confusion during evacuation.
K351 Sprinkler System - Installation: The facility failed to ensure a complete automatic fire sprinkler system in the attic, missing sprinkler heads.
K353 Sprinkler System - Maintenance and Testing: The facility failed to maintain sprinkler heads free of paint, potentially delaying activation.
K362 Corridors - Construction of Walls: The facility failed to protect emergency corridors by allowing windows and activity rooms to remain open.
K363 Corridor - Doors: The facility failed to ensure corridor doors resisted smoke passage, allowing resident room doors to remain with gaps or non-sealed latches.
K374 Subdivision of Building Spaces - Smoke Barrier Doors: The facility failed to maintain smoke barrier doors, allowing a wooden astragal to remain without fire resistance.
K523 HVAC - Suspended Unit Heaters: The facility failed to maintain suspended electric heaters in the attic, allowing continuous operation with high ambient temperatures.
K711 Evacuation and Relocation Plan: The facility failed to ensure staff were properly trained on fire alarm pull stations and fire extinguisher use.
K781 Portable Space Heaters: The facility failed to remove a portable electric heater from the Director of Nursing's office.
K911 Electrical Systems - Other: The facility failed to remove temporary electrical lighting from the attic after construction completion.
K918 Electrical Systems - Essential Electric System Maintenance and Testing: The facility failed to conduct annual fuel quality testing for the emergency generator.
K919 Electrical Equipment - Other: The facility failed to ensure proper use of power outlets by allowing furniture to block cords and plugs in resident rooms.
K920 Electrical Equipment - Power Cords and Extension Cords: The facility failed to ensure safe use of electrical cords, allowing unapproved extension cords and cords under pressure.
K923 Gas Equipment - Cylinder and Container Storage: The facility failed to maintain proper storage and separation of oxygen cylinders.
A2003 No Fire Hazard: The facility presented a fire hazard as referenced in K523.
A2008 Hazardous Areas: The facility failed to maintain hazardous areas as referenced in K223.
A2010 Oxygen Storage: The facility failed to properly store oxygen cylinders as referenced in K923.
A2034 Sprinkler System-Test/Maintain: The facility failed to maintain sprinkler system as referenced in K351 and K353.
A2037 Exit Requirements: The facility failed to meet exit requirements as referenced in K222 and K271.
A2046 Corridor Requirements: The facility failed to maintain corridors as referenced in K232.
A2048 Exit Sign Placement/Letter Size: The facility failed to maintain exit signage as referenced in K293.
A2050 Emergency Lighting: The facility failed to provide emergency lighting as referenced in K281.
A2059 Fire Drills - Plan Requirements: The facility failed to maintain fire drill and emergency preparedness plans as referenced in K711.
A3001 Substantially Constructed/Maintained: The facility failed to maintain the building in good repair as referenced in K362, K363, and K918.
A3027 Heating System-No Portable: The facility failed to restrict portable heaters as referenced in K781.
A3030 Electrical Wiring & Equipment Maintained: The facility failed to maintain electrical wiring and equipment as referenced in K919 and K920.
Report Facts
Facility capacity: 100
Resident census: 77
Inspection Report
Plan of Correction
Census: 77
Capacity: 100
Deficiencies: 5
Date: Jul 31, 2018
Visit Reason
The document is a Plan of Correction submitted by Shepherd of the Hills Living Center following a state survey conducted on 07/31/2018. The purpose is to address deficiencies cited during the inspection and outline corrective actions.
Findings
The facility was found deficient in multiple areas including failure to ensure residents' choice of code status was accessible and consistent, incomplete baseline care plans within 48 hours of admission, medication administration errors related to insulin, unsanitary food contact surfaces, and inadequate resident call system. The facility census was 77 with a total licensed capacity of 100 beds.
Deficiencies (5)
F-578 The facility failed to ensure a resident's choice of code status was accessible and consistent across medical records and documentation.
F-655 The facility failed to develop and document baseline care plans within 48 hours of admission for multiple residents.
F-760 The facility failed to administer insulin in a timely and accurate manner according to physician orders and nursing standards.
F-812 The facility failed to maintain food contact surfaces in a sanitary condition, including failure to clean vents, shelving, and removal of dented cans.
F-919 The facility failed to provide an adequate resident call system, including missing call light switches in toilet rooms.
Report Facts
Facility census: 77
Total licensed capacity: 100
Sample size for record review: 18
Viewing
Loading inspection reports...
