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? |
|---|---|---|---|---|
| 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 |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2018-07-31 | 2018-09-14 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-07-31 | 2018-09-14 | N |
| Ensure that residents are free from significant medication errors. | Health | 2018-07-31 | 2018-09-14 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-07-31 | 2018-09-14 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2018-07-31 | 2018-09-14 | N |
| Establish an Emergency Preparedness Program (EP). | Fire Safety | 2018-07-31 | 2018-09-14 | 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 | 2018-07-31 | 2018-09-14 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2018-07-31 | 2018-09-14 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2018-07-31 | 2018-09-14 | N |
| Have exits that are accessible at all times. | Fire Safety | 2018-07-31 | 2018-09-14 | N |
| Install proper backup exit lighting. | Fire Safety | 2018-07-31 | 2018-09-14 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2018-07-31 | 2018-09-14 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2018-07-31 | 2018-09-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-07-31 | 2018-09-14 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-07-31 | 2018-09-14 | N |
| Ensure that HVAC heat units are suspended and out of the reach of patients and can be shut off if unit is working improperly. | Fire Safety | 2018-07-31 | 2018-09-14 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2018-07-31 | 2018-09-14 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2018-07-31 | 2018-09-14 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2018-07-31 | 2018-09-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2018-07-31 | 2018-09-14 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2018-07-31 | 2018-09-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-07-31 | 2018-08-08 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2018-07-31 | 2018-08-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2018-07-31 | 2018-08-06 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2018-07-31 | 2018-08-04 | N |
