Shepherd Hills Senior Care LLC

Based on documentation review, record review, and interview, the manager failed to ensure, for two of two sampled residents, a documented residency agreement accurately included whether the manager or a caregiver is awake during nighttime hours. Findings include: 1. A documentation review of the facility work schedule revealed on each week in August 2025, E3 started a shift on Friday at 5 PM and worked through the following Monday at 8 AM, a 63 hour shift. The work schedule indicated E3 was the only caregiver on duty during the weekend shift. 2. A review of R1's and R2's medical records revealed each resident had a documented residency agreement. Each agreement stated, "At this facility, the caregiver will remain awake during the nighttime hours in order to meet the needs of the residents." 3. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on observation and interview, the manager failed to ensure food requiring refrigeration was maintained at 41° F or below. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed two refrigerators in the kitchen, both used to store foods requiring refrigeration. The refrigerator on the right side had a thermometer at the back of the top shelf, a location normally the coldest location in a refrigerator. However, the thermometer read 44° F. 2. Approximately one hour later, the Compliance Officer rechecked the refrigerator and observed the thermometer read 49° F. 3. In an exit interview, the findings were reviewed with E1 and no additional information was provided.

Based on documentation review, observation, and interview, the manager failed to ensure the means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort, controlled or alerted employees of the egress of a resident from the facility. The deficient practice posed a risk if the facility was unaware of the general or specific whereabouts of a resident. Findings include: 1. A documentation review of the license issued by the Department revealed the facility was authorized to provide directed care services. 2. During a facility tour, the Compliance Officer observed a side door in the hallway adjacent to bedroom #7. The side door was equipped with a door alarm, however, the door alarm was observed to be non-functional. 3. During a facility tour, the Compliance Officer observed the front door. The front door had a door alarm attached the door, however, the magnet was missing from the door frame and the door alarm was observed to be non-functional. 4. In an interview, E1 acknowledged the means of exiting the facility for a resident who does not have a key, special knowledge for egress, or the ability to expend increased physical effort did not control or alert employees of the egress of the resident. This is a repeat deficiency from the on-site compliance survey conducted on September 12, 2022.

Based on observation and interview, the manager failed to ensure potentially hazardous foods requiring refrigeration were maintained at 41\'b0F or below. Findings include: 1. The Compliance Officer observed a refrigerator in the kitchen contained food items. The Compliance Officer observed a thermometer in the door of the refrigerator measured the temperature of the refrigerator at 48\'b0F. The Compliance Officer observed the refrigerator contained items requiring refrigeration such as milk, juice, creamer, and ketchup. A second thermometer was placed in the refrigerator at this time. 2. Approximately two hours after the start of the inspection, the Compliance Officer checked the refrigerator again and observed both thermometers measured the temperature of the refrigerator at 46\'b0F. 3. In an interview, E1 acknowledged the refrigerator's temperature had not been maintained at 41\'b0F or below.