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Deficiency Records for Shepherd of The Hills Living Center
A list of the most recent deficiencies for Shepherd of The Hills Living Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Shepherd of The Hills Living Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-03-21 | 2024-05-06 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2024-03-21 | 2024-05-06 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-03-21 | 2024-05-06 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-03-21 | 2024-05-06 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-03-21 | 2024-05-06 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-03-21 | 2024-05-06 | N |
| Provide bedrooms that don't allow residents to see each other when privacy is needed. | Health | 2024-03-21 | 2024-05-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-21 | 2024-05-06 | Y |
| Use approved construction type or materials. | Fire Safety | 2024-03-25 | 2024-05-06 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2024-03-25 | 2024-05-06 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-03-25 | 2024-05-06 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-03-25 | 2024-05-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-03-25 | 2024-05-06 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-03-25 | 2024-05-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-03-25 | 2024-05-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-03-25 | 2024-05-06 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-03-25 | 2024-05-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-20 | 2023-12-21 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-09-29 | 2023-10-31 | Y |
| Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency. | Health | 2022-07-28 | 2022-09-11 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-07-28 | 2022-09-11 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-07-28 | 2022-09-11 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2022-07-28 | 2022-09-11 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-07-28 | 2022-09-11 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-07-28 | 2022-09-11 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-07-28 | 2022-09-11 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-07-28 | 2022-09-11 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-07-28 | 2022-09-11 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-28 | 2022-09-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-07-28 | 2022-09-11 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-07-28 | 2022-09-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-07-28 | 2022-08-27 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-09-03 | 2019-10-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-03 | 2019-10-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-03 | 2019-10-18 | N |
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