Below average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Shepherd Of The Hills Living Center during CMS and state inspections, most recent first.
RN coverage was not maintained for at least 8 consecutive hours per day, 7 days per week, because the facility had multiple weekends with no RN scheduled and, on some days, no RN time logged at all. The DON said the facility relied on the DON, one prn RN, and the MDS RN to fill gaps, but the facility had no specific RN coverage policy and acknowledged it was not always in compliance with the required RN coverage.
Failure to complete CBCs before hire was cited after record review showed two sampled employees did not have documented CBCs before their hire/start dates. The facility’s abuse prohibition policy required FCSR/EDL and CBC screening before any contact with residents, but one DA had a CBC request documented months after hire and one HK employee had no documented completed CBC. The Asst. BOM, DON, QA RN, and Administrator all acknowledged that background checks are to be completed before staff work with residents.
A medication refrigerator in the med room was found at 31 degrees Fahrenheit while storing influenza vaccine, Lantus, and NovoLog that required 36 to 46 degrees Fahrenheit. Temperature logs also had multiple missing entries over several months, and staff interviews showed inconsistent knowledge of the required range and routine monitoring responsibilities.
Staff failed to follow infection control practices during resident care, including EBP and hand hygiene. During wound care for a resident with chronic wounds and a Foley catheter, the ADON and DON did not wear gowns, and the ADON handled the catheter bag, resident gown, and supplies without hand hygiene before changing gloves. During PEG tube medication administration for another resident, an LPN used gloves but no gown while verifying tube placement, flushing a clogged tube, and giving medications. During a diabetic accu-check and insulin administration for a resident with diabetes, a CMT repeatedly donned and doffed gloves without performing hand hygiene.
A resident with severe cognitive impairment, diabetes, atrial fibrillation, reduced mobility, and a history of falls had an incomplete care plan. The plan addressed oxygen use but did not include insulin monitoring, anticoagulant monitoring for Eliquis, high fall-risk interventions, or toileting needs, even though the resident was always incontinent and required extensive assistance with ADLs.
Incomplete Neurological Assessments After Unwitnessed Falls: Nursing staff failed to complete required neurochecks after unwitnessed falls for two residents. One resident had CKD, retroperitoneal hematoma, diabetes, used a walker, and had multiple falls, while the other had dementia, prior fractures, head injury, severe cognitive decline, and high fall risk. Facility records showed missed neurological assessment entries across multiple shifts after falls, and staff interviews confirmed neurochecks were expected after unwitnessed falls to monitor for changes in condition and possible brain bleeds.
A resident with severe cognitive impairment, weakness, reduced mobility, encephalopathy, and type 2 DM was assessed by the RD as needing 2000 plus cc of fluids daily, but intake records showed repeated days below that amount. Surveyors observed the resident sitting for long periods in the day room, TV room, dining room, and activity room without drinks nearby, and staff did not consistently offer fluids even when checking blood glucose, moving the resident, or after toileting when the brief was dry and urine was dark and concentrated. Interviews confirmed the resident needed prompting to drink and that fluids should be offered at least every two hours.
A resident with a history of CHF and COPD was admitted with a cardiac life vest, but staff did not obtain a physician order, include the device in the care plan, or monitor its use as required. Multiple staff interviews revealed a lack of awareness and training regarding the device, and documentation failed to address its application, maintenance, or monitoring, resulting in a deficiency.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
The facility failed to supervise residents during medication administration, leaving medications unattended in rooms, and did not investigate a fall where a resident went down on one knee. Staff admitted to being overwhelmed and not following policies, leading to deficiencies in medication administration and fall investigation protocols.
A resident with moderate cognitive impairment and respiratory issues was allowed to keep and use an albuterol inhaler at their bedside without a documented self-administration assessment or a physician's order. Staff acknowledged the resident's independent use of the inhaler, but the facility's policy requiring an assessment and order was not followed.
The facility failed to fully resolve a resident's grievance regarding $200.00 missing. Only $100.00 was found, and the investigation was stopped prematurely, leaving the grievance unresolved.
The facility failed to ensure that two residents received adequate grooming and personal hygiene care, including nail trimming and shaving. One resident did not receive the scheduled twice-weekly baths or showers. Staff interviews and observations confirmed these deficiencies.
The facility failed to monitor and document the bruit and thrill of a resident's AV shunt for dialysis services. The resident, with ESRD, did not have an order for such checks until identified during a survey. Staff confirmed they did not routinely assess the bruit and thrill, and the DON was unaware of the lack of an order prior to the survey.
The facility failed to ensure the physician reviewed and acted upon medication irregularities reported by a Consultant Pharmacist in a timely manner for a resident with dementia. The pharmacist's recommendations regarding PRN orders and lab tests were not addressed until after the survey was initiated, despite being communicated to the facility staff. The resident was frequently observed sleeping and difficult to awaken.
The facility failed to ensure an expired medication was not stored in a resident's room. A tube of hydrocortisone cream with an expiration date of [DATE] was found in a resident's room. An LPN confirmed the presence of the expired cream, and the DON was unaware of it, despite facility policy requiring periodic checks by CNAs.
The facility failed to ensure a privacy curtain was in place between two residents sharing a semi-private room. Observations over three days showed the curtain was missing, and staff interviews revealed it was removed for washing and not replaced due to a limited supply. The DON and Administrator emphasized the importance of privacy curtains, regardless of residents' cognitive status.
RN Coverage Not Maintained on Weekends
Penalty
Summary
The facility failed to provide the services of an RN for at least eight consecutive hours per day, seven days per week, when it did not have consistent RN coverage on weekends. The facility census was 75, and review of the nurse schedule, timecard reports for all RNs, and the Salaried Personnel - Direct Resident Care Logs for December 2025, January 2026, and February 2026 showed multiple weekend shifts with no RN scheduled and, on some dates, no RN logged time at all. On several Saturdays and Sundays, the only RN coverage came from the MDS Coordinator/RN for less than eight hours, including 6.9 hours, 4.4 hours, 3.8 hours, 4.4 hours, 4.7 hours, and 4.1 hours on different weekends. During interviews, RN K said he/she worked every other weekend and was not sure how RN coverage was scheduled on alternate weekends or when he/she had requested off. The DON said the facility had only one floor RN who worked every other weekend and that they tried to fill alternate weekends with the DON, one prn RN, and the MDS Coordinator/RN, with the DON recording floor time on the salaried time log and the other RNs using the time clock. The DON also stated the facility did not have a policy specific to RN coverage and that they should just follow the regulations. The Administrator acknowledged the facility had a shortage of RNs and that there were gaps on some weekends, so they were not always in compliance with the required RN coverage of eight consecutive hours daily.
Failure to Complete CBCs Before Hire
Penalty
Summary
Develop and implement policies and procedures to prevent abuse, neglect, and theft was cited after record review and interview showed the facility did not complete criminal background checks (CBCs) for two of ten sampled employees before their hire/start dates. The facility’s Abuse Prohibition Protocol Manual stated that employees and volunteers are to be screened prior to working with residents, including verification of references, licensure, and a CBC, and that the Family Care Safety Registry (FCSR) or Employee Disqualification List (EDL) and CBC must be checked before an applicant has any contact with residents. It also stated that a CBC request and results should be kept in each employee file. Review of the employee records showed Dietary Aide U had a hire date of 11/17/25, but the CBC request was not documented until 02/12/26 and no completed CBC was documented before that date. Housekeeping V had a hire date of 04/14/25, and the facility did not document a completed CBC for that employee. During interview, the Asst. BOM said he/she was responsible for background checks and new employee education, and stated there had been delays and misinformation with the FCSR process. The DON, QA RN, and Administrator all stated that full background checks are to be completed prior to hire and that staff cannot work with residents until the CBC is done.
Medication Refrigerator Stored Drugs Below Required Temperature
Penalty
Summary
The facility failed to maintain the medication storage refrigerator at the recommended temperatures for refrigerated medications and vaccines. The facility policy required refrigerated biologicals and medications to be kept in a securely fastened refrigerator and stored between 36 and 46 degrees Fahrenheit. CDC guidance and package inserts for influenza vaccine, Lantus, and NovoLog also required refrigerated storage between 36 and 46 degrees Fahrenheit and stated that these products should not be frozen. During observation, the medication refrigerator in the medication room contained five boxes of influenza vaccine, 25 pens of Lantus, and 25 pens of NovoLog, and the refrigerator temperature measured 31 degrees Fahrenheit. Review of temperature logs for December 2025 through February 2026 showed multiple missing entries on numerous dates. Staff interviews showed that night shift nursing staff were responsible for checking and documenting refrigerator temperatures, but several staff members were unsure of the exact required range. The ADON, DON, pharmacist, and Administrator all stated that refrigerated medications should be maintained between 36 and 46 degrees Fahrenheit and that staff should monitor and report temperature problems, but the refrigerator was observed below range and the logs were incomplete.
Infection Control Lapses During Wound Care, Tube Feeding Medication Administration, and Accu-Checks
Penalty
Summary
The facility failed to establish and maintain a complete infection control program when staff did not consistently use hand hygiene and Enhanced Barrier Precautions (EBP) during resident care. The report states that staff failed to use proper hand hygiene and EBP during wound care for one resident, during medication administration for another resident with a feeding tube, and during diabetic accu-checks for a resident with diabetes. The facility census was 75, and a sample of 16 residents was reviewed. One resident had chronic venous ulceration of the right lower extremity, a pressure ulcer of the back, and a pressure ulcer of the right buttock. The resident also had a Foley catheter and was identified in the care plan and physician orders as requiring EBP related to the catheter and pressure ulcer. During observed wound care, nursing staff washed hands and donned gloves, but the ADON and DON did not don gowns. While assisting with turning the resident, the ADON picked up and moved the Foley catheter bag with gloved hands, touched the resident gown, covered the resident, and then picked up pen and paper and moved them to the dresser before changing gloves and without performing hand hygiene. Another resident had a PEG tube, was NPO, and received continuous tube feeding and medications through the tube. The resident’s care plan and physician orders identified EBP related to the PEG tube. During observation, an LPN used hand sanitizer and gloves but did not don a gown before entering the room. The LPN verified tube placement, flushed the tube, managed a clogged tube by massaging it, administered medications through the tube, flushed again, and restarted the feeding pump. A third resident with diabetes was observed during an accu-check and insulin administration, during which a CMT donned gloves without performing hand hygiene, completed the blood sugar check, doffed gloves, obtained insulin, donned gloves again without hand hygiene, administered insulin, doffed gloves, and charted results without performing hand hygiene.
Incomplete Care Plan for Resident With Diabetes, Anticoagulant Use, Falls, and Toileting Needs
Penalty
Summary
The facility failed to complete a comprehensive and individualized care plan for one resident with multiple identified needs. Resident #10 had diagnoses including weakness, reduced mobility, atrial fibrillation, hypertension, left femur fracture, diarrhea, constipation, insomnia, depression, encephalopathy, and type 2 diabetes. The resident’s quarterly MDS showed severe cognitive impairment, always incontinent of bowel and bladder, extensive to total assistance needed for bed mobility, transfers, toileting, and locomotion, two or more falls since admission or reentry, insulin injections, and anticoagulant use. The resident’s care plan revised on 01/06/26 addressed impaired gas exchange related to chronic respiratory failure and oxygen administration, but it did not address the resident’s diabetes, insulin use, or signs and symptoms to monitor for blood glucose problems. The care plan also did not address the resident’s anticoagulant use or any monitoring for signs and symptoms related to that medication. In addition, the care plan did not address the resident’s high fall risk or any interventions to prevent falls. The record review also showed that the resident was prescribed Eliquis 2.5 mg twice daily and Novolog FlexPen insulin on a sliding scale before meals and at bedtime. The bowel/bladder assessment showed the resident was always incontinent of bowel and urine, had constipation, was not assessed for a urinary toileting program, and was never aware of toileting needs. Staff interviews reflected that toileting information, fall risk information, anticoagulant monitoring, and diabetic monitoring were expected to be on the care plan, but these items were not included for this resident.
Incomplete Neurological Assessments After Unwitnessed Falls
Penalty
Summary
The facility failed to ensure residents received care and treatment in accordance with professional standards of practice when nursing staff did not complete neurological assessments after unwitnessed falls for two residents. The facility policy on condition changes, including falls, required staff to observe for signs such as lacerations, swelling, changes in consciousness, unequal pupils, weakness, speech disorder, gait change, and other neurological changes, and to monitor the resident frequently until stable. The facility also provided a neurological check worksheet indicating checks should be completed every 15 minutes times 4, every 30 minutes times 2, every hour times 2, and every shift for 72 hours, with nurses’ notes reflecting the assessments. One resident had diagnoses including chronic kidney disease, retroperitoneal hematoma, and diabetes, used a walker, had no cognitive impairment, depressed mood, and multiple falls since admission. After unwitnessed falls documented by nursing staff, neurological checks were started, but the record showed missed neurological assessments on multiple shifts following the falls. The resident’s chart showed gaps in the neurological assessment documentation after falls on 11/23/25, 12/04/25, 12/11/25, and 01/19/26, with several required shift assessments not completed. The second resident had diagnoses including dementia, history of hip fracture, history of neck fracture, and head injury, with significant memory loss, severe cognitive decline, impaired transfers, and high fall risk. After an unwitnessed fall in the resident’s bedroom with a cut on the back of the hand, the fall report directed staff to complete neurochecks for 72 hours, but the neurological check section was left blank. The progress notes did not show the required ongoing assessments during the 72 hours after the fall, and only a later note documented pupils equally reactive and responsive to light. Staff interviews confirmed that neurological checks were expected after unwitnessed falls and were important to identify changes in condition and possible brain bleeds.
Failure to Consistently Offer Fluids to a Cognitively Impaired Resident
Penalty
Summary
The facility failed to ensure adequate fluid intake for a resident who was assessed by the RD as needing 2000 plus cc of fluids per day and who had diagnoses including weakness, reduced mobility, encephalopathy, and type 2 diabetes. The resident’s quarterly MDS showed severe cognitive impairment, and the care plan identified the resident as at risk for inadequate oral intake with directions to observe intake of food and fluids, update preferences, and offer snacks between meals. The facility policy on hydration stated that water should be distributed each shift, assistance should be given to residents unable to drink independently, and between-meal hydration programs should promote fluid intake. The resident’s intake and output records showed multiple days of fluid intake below the RD’s suggested amount, including totals of 1420 cc, 1220 cc, 1460 cc, 1130 cc, 1300 cc, 1460 cc, 860 cc, and 480 cc. On observation, the resident spent extended periods sitting in a wheelchair in the day room, common TV room, dining room, and activity room without drinks nearby. Staff observed by surveyors did not consistently offer fluids while the resident remained in these areas, including when an LPN checked blood glucose and when a CNA moved the resident from one area to another. During the observation, the resident was eventually provided drinks at lunch, including Kool-Aid, coffee, and a shake supplement, and staff prompted and assisted with eating. Later, after the resident was taken to the bathroom, the brief was dry and the urine was described as dark and concentrated. Staff then returned the resident to the wheelchair and again did not offer a drink. Interviews with CNAs, NAs, an LPN, the DON, and the Administrator confirmed that the resident needed prompting to drink, that fluids should be offered at least every two hours, and that staff would expect residents in day room or activity room areas to be passed water during shifts.
Failure to Obtain Physician Order and Care Plan for Cardiac Life Vest
Penalty
Summary
The facility failed to obtain a physician order, develop a care plan, and monitor the use of a cardiac life vest for one resident with a history of congestive heart failure and chronic obstructive pulmonary disease. Upon admission, the resident was wearing a cardiac life vest, but staff did not address its use in the admission assessment or care plan. Nursing progress notes mentioned the presence of the life vest, but there was no documentation in the physician progress notes or the physician order sheet regarding its use, application, battery changes, cleaning, or monitoring requirements. Interviews with various staff members, including LPNs, CNAs, the MDS Coordinator, the ADON, and the DON, revealed a lack of awareness, training, and experience regarding the care and monitoring of cardiac life vests. Staff consistently stated that a physician order and care plan should have been in place for the life vest, including instructions for skin assessments, battery changes, and monitoring. However, none of these actions were documented or implemented for the resident in question. The deficiency was further evidenced by the absence of any mention of the cardiac life vest in the care plan and the lack of staff education on its use. The resident's use of the device was only discovered after admission, and staff relied on the resident to manage aspects of the device, such as battery changes. The facility's policies required individualized care planning and current physician orders for all treatments and devices, but these were not followed in this case.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations.
Medication Administration and Fall Investigation Deficiencies
Penalty
Summary
The facility failed to ensure nursing staff supervised residents during medication administration, resulting in medications being left unattended in residents' rooms. For instance, Resident #51, who was cognitively intact, had a cup containing three white pills left in their room. The resident admitted to falling asleep before taking all their medications. Similarly, Resident #33, who had moderate cognitive impairment, had a medication cup with several tablets left in their room. The Certified Medication Technician (CMT) admitted to leaving the medications, trusting the resident would take them, despite knowing the policy against it. Additionally, Resident #46, with moderate cognitive impairment, had various medications left at their bedside, which the resident did not know why they were there. The Licensed Practical Nurse (LPN) confirmed that medications should not be left at the bedside. Resident #7, who was cognitively intact, also had multiple medications left at their bedside, which the LPN acknowledged should have been stored in the treatment cart instead of the resident's room. The facility also failed to identify and investigate a fall for Resident #48, who had moderate cognitive impairment and was at risk for falls due to COPD exacerbation. The resident reported getting tangled in their oxygen tubing and going down on one knee but managed to get up and into bed. The LPN did not consider this incident a fall because only one knee touched the ground, contrary to the facility's policy that any knee touching the ground should be considered a fall. As a result, no fall assessment or documentation was completed for this incident. Interviews with staff, including LPNs and the Director of Nursing (DON), revealed that medications were sometimes left unattended due to staff being overwhelmed with their workload. The DON and Administrator both emphasized that medications should not be left at residents' bedsides and that any fall, including one where a knee touches the ground, should be investigated and documented according to the facility's policies. The failure to follow these policies led to deficiencies in medication administration and fall investigation protocols.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure staff assessed a resident to determine if they were clinically appropriate and safe to self-administer medications before allowing them to do so. Specifically, Resident #30, who had moderate cognitive impairment and was diagnosed with acute respiratory failure, hypoxia, hypercapnia, and acute bronchitis, was allowed to keep and use an albuterol inhaler at their bedside without a documented self-administration assessment or a physician's order for self-administration. The resident's care plan did not address their ability to self-administer medications, and there was no documentation of a self-administration evaluation in the resident's observation history. During interviews, staff members, including a Certified Medication Technician and the Director of Nursing, acknowledged that the resident had an inhaler at their bedside and administered it independently. However, the Director of Nursing confirmed that no residents in the facility had been approved to self-administer medications, and a self-administration assessment should have been completed and documented in the electronic medical record. The facility's policy required an interdisciplinary team assessment and a physician's order for self-administration, which were not followed in this case.
Failure to Fully Resolve Resident Grievance
Penalty
Summary
The facility failed to resolve a grievance and document the full resolution for a resident who reported $200.00 missing. The resident, who was cognitively intact and had multiple diagnoses including chronic diastolic heart failure, acute kidney failure, anemia, type 2 diabetes mellitus with hyperglycemia, and chronic pain syndrome, initiated a grievance on 02/05/24. The facility's grievance policy required a thorough investigation and a written decision within 30 days. However, the investigation was incomplete as only $100.00 was found, and the remaining $100.00 was not accounted for. The Director of Nursing (DON) and the Social Worker (SW) stopped the investigation after locating part of the missing money and did not continue efforts to resolve the grievance fully. Interviews with the resident, DON, and SW revealed that the facility did not follow through with the grievance process as outlined in their policy. The resident confirmed that $100.00 was still missing and that no further action was taken by the facility. The SW, who served as the grievance coordinator, admitted to stopping the investigation after some of the money was found and did not document a full resolution. This failure to fully investigate and resolve the grievance led to the deficiency noted in the report.
Failure to Provide Adequate Grooming and Personal Hygiene Care
Penalty
Summary
The facility failed to ensure that two residents received adequate grooming and personal hygiene care. Specifically, the staff did not provide nail care and did not shave the facial hair of the two residents. Additionally, one resident did not receive the scheduled twice-weekly baths or showers in March 2024. The facility's policy on Activities of Daily Living (ADL) did not address shaving or nail care, and the Certified Nursing Assistant (CNA) job description, although dated May 2006, did not explicitly include these tasks either. Resident #12, who had diagnoses including weakness, chronic pain, and aphasia, was dependent on staff for bathing and required assistance with personal hygiene. The resident's care plan did not include specific interventions for personal hygiene needs. Observations and interviews revealed that the resident had long nails and facial hair that needed trimming. The last documented shower for this resident was on March 14, 2024, and staff did not document nail or shaving care on that day. Interviews with CNAs and LPNs indicated that the resident did not refuse ADL care, but the staff failed to provide the necessary grooming services. Resident #72, who had diagnoses including pain, reduced mobility, and osteoarthritis, needed assistance with showers and personal hygiene. The resident's care plan also lacked specific interventions for personal hygiene. Observations and interviews showed that the resident had long fingernails and facial hair and did not receive the scheduled showers. The resident reported receiving a shower only once a week and not being offered nail trimming or shaving. Staff interviews confirmed that the resident did not always refuse showers, but the staff failed to provide adequate bed baths, nail trimming, and shaving as needed.
Failure to Monitor and Document AV Shunt for Dialysis Resident
Penalty
Summary
The facility failed to monitor and document the bruit and thrill of a resident's arteriovenous (AV) shunt for a resident requiring dialysis services. The facility's policy required daily checks and documentation of the thrill sensation at the AV shunt site, but this was not done for Resident #61. The resident, who had end-stage renal disease (ESRD) and received dialysis three times a week, did not have an order to check the bruit and thrill until it was added during the survey. Staff confirmed that they did not routinely assess the bruit and thrill, and the Director of Nursing (DON) was unaware of the lack of such an order prior to the survey. Interviews with staff revealed that while some nurses checked the AV shunt site for signs of infection, swelling, or bleeding, they did not consistently check the bruit and thrill. The resident also confirmed that nursing staff did not routinely use a stethoscope to assess the AV shunt site. The DON and the Administrator both expected an order to be in place for monitoring and documenting the bruit and thrill, but this was not implemented until the survey identified the deficiency.
Failure to Address Pharmacist's Medication Recommendations
Penalty
Summary
The facility failed to ensure the physician reviewed and acted upon medication irregularities reported by a Consultant Pharmacist in a timely manner for one resident. The resident, who had diagnoses including non-Alzheimer's dementia and unspecified disorientation, was on multiple medications such as antipsychotics, hypnotics, and opioids. The pharmacist identified several issues with the resident's medication orders, including duplicate PRN orders for lorazepam without specified dosing intervals, a PRN order for Robitussin lacking a dosing interval, and a recommendation for lab tests related to the use of divalproex acid. These recommendations were not addressed by the prescribing physician until after the survey was initiated, despite being communicated to the facility staff in a timely manner by the pharmacist. The resident was frequently observed sleeping and difficult to awaken, which was also noted by the resident's representative during visits. Interviews with the Pharmacy Consultant, Medical Director, DON, and Administrator revealed a lack of awareness and follow-up on the pharmacist's recommendations, leading to the deficiency.
Expired Medication Found in Resident's Room
Penalty
Summary
The facility failed to ensure an expired medication was not stored in a resident's room. Specifically, a tube of hydrocortisone cream with an expiration date of [DATE] was found in Resident #8's room. The facility's policy mandates that all medications must be stored in locked compartments and that no outdated drugs may be retained for use. During an interview, an LPN confirmed the presence of the expired cream and stated they had not previously seen it. The DON also confirmed being unaware of the expired medication and mentioned that CNAs are expected to periodically check for and remove any medications found in residents' rooms.
Failure to Provide Privacy Curtain in Semi-Private Room
Penalty
Summary
The facility failed to ensure a privacy curtain was in place between two residents who shared a semi-private room. Observations over three consecutive days showed that the privacy curtain between the beds was missing. Interviews with staff revealed that the curtain had been taken down for washing and was not replaced due to a limited supply of replacement curtains. The CNA did not recall if there had ever been a privacy curtain and did not consider it a concern due to the poor cognition of both residents. The LPN was unaware of the missing curtain and would have contacted housekeeping or maintenance if informed. The Environmental Supervisor confirmed the curtain was removed for washing and acknowledged the limited supply of replacements. The Director of Nursing and the Administrator both stated that semi-private rooms should have privacy curtains to provide privacy for the residents, regardless of their cognitive status. The Administrator was not aware of the limited supply of privacy curtains and emphasized that a replacement should be hung immediately when one is taken down. The deficiency highlights a lapse in ensuring resident privacy due to inadequate inventory management and communication among staff.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 28 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Branson
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Point Lookout Nursing & Rehab | 2.6 mi | ★★★★★ | 1 | 0 |
| Forsyth Care Center | 6.7 mi | ★★★★★ | 16 | 0 |
| Ozark Riverview Manor | 24.9 mi | ★★★★★ | 11 | 0 |
| Ozark Care & Rehab Center | 25.5 mi | ★★★★★ | 5 | 0 |
| The Blossoms At Berryville Rehab & Nursing Center | 27.6 mi | ★★★★★ | 16 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Shepherd Of The Hills Living Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.