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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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