Shepherd of the Hills Living Center

In the surveyor’s words

From the most serious findings on record at Shepherd of the Hills Living Center, in the surveyor’s own words.

• Actual harm, isolatedF689Nov 20, 2023

  Based on observations, interviews, and record review, the facility failed to provide protective oversight to one resident (Resident #1), when staff failed to place foot rests on the resident's wheelchair, and the resident subsequently fell out of the wheelchair sustaining a facial laceration and a broken nose. The facility census was 78. Review of the facility policy titled, Use of Wheelchair, undated, showed the following: -Purpose to provide mobility for the non-ambulatory resident with safety and comfort and to provide mobility for residents learning to become independent in activities of daily living; -Apply brakes to lock wheels of wheelchair and fold footrests up out of the resident's way for safety; -Do not remove footrests unless resident uses feet on floor to enable mobility; -Pad… […]

• No harm, potential for more than minimal, widespreadF761Jul 30, 2026

  Based on observation and interview, the facility failed to ensure all medication was secured when medication and treatment carts were left unlocked, medication keys were left in box on top of the medication cart, and keys were left in the door lock of the medication room. The facility census was 77.Review of the facility policy, titled Storage of Medication, dated July 2021, showed the following:-Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier;-The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, pharmacy personnel, or staff members lawfully authorized to administered medications;-Medication rooms, carts, and medication supplies are locked when not attended by… […]

• No harm, potential for more than minimal, widespreadF727Feb 13, 2026

  Based on interview and record review, the facility failed to provide the services of a registered nurse (RN) for at least eight consecutive hours per day seven days per week when the facility did not have consistent RN coverage on the weekends. The facility census was 75.Review showed the facility did not have a specific policy pertaining to the scheduling of an RN. 1. Review of the facility's nurse schedule, timecard reports for all RNs, and facility form entitled Salaried Personnel - Direct Resident Care Logs (Salaried Time Log - logged working hours by salaried employee), dated December 2025, January 2026, and February 2026, showed the following:-On Saturday, 12/06/25, no RN was scheduled. […]

• No harm, potential for more than minimal, widespreadF812Jul 28, 2022

  Based on record review, observation, and interview, the facility failed to store food in accordance with professional standards of practice and protect food from possible contamination when staff did not store dry food properly after opening and staff did not wear proper hair coverings. The facility census was 77. 1. Record review of the 2013 Missouri Food Code showed the following information: -Food shall be protected from contamination by storing the food in a clean, dry location and where it is not exposed to splash, dust, or other contamination. Record review showed the facility did not have a policy regarding dry food storage. […]

• No harm, potential for more than minimal, patternF607Feb 13, 2026

  Based on record review and interview, the facility failed to implement their abuse and neglect policies when staff failed to complete criminal background checks (CBCs) for two of ten sampled employees prior to their hire/start date in a facility with a census of 75. Review of the facility's Abuse Prohibition Protocol Manual (effective 11/28/2016) showed the following:-The facility must develop and implement written policies and procedures that: -prohibit and prevent abuse, neglect, and exploitation of residents, and misappropriation of property;-It is the policy of this facility to screen employees and volunteers prior to working with residents. […]