Shepherd's Inn

Based on record review, the licensee did not comply with the section cited above in 5 out of 5 resident files, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on records review, the licensee did not comply with the section cited above in 5 out of 5 residents which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in that no carbon monoxide detectors were found working at the facility which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in that water temperature was measured at 139.6 degrees F which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation & interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed garage to not be maintained and is accessible to residents.

Based on observation & interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. During the visit on 7/9/24 LPA observed cleaning supplies & toxins to be unlocked and accessible under the kitchen sink and a cabinet on the side of the sink.

Based on observation & interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed a sample of resident files which did not have completed centrally stored medication logs.

Based on observation, interview, record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA did not observe proper documentation in resident's files regarding a change in status.

Based on observation & interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed kitchen in garage to be contaminated with droppings from rodents, dirty dishes and trash were in garage.

Based on observation & interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed additional kitchen area to be kept in the garage which is used for cooking fish according to the Licensee. LPA observed kitchen to be kept unclean which does not prevent rodents and insect causing items in the garage to not be clean or sanitized.

Based on observation & interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed non-perishable food items to not be kept in clean area away from rodent droppings. LPA observed food items in refrigerators to not be properly labeled.

Based on observation, interview, & record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation & interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed a container with rice to be been chewed through by a rodents leaving the rice to be contaminated. Disposable cups were also contaminated due to being chewed by rodents.

Based on observation & interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. Due to food being kept in the garage it is considered contaminated and needs to be maintained.

Based on observation, interview, & record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. During the annual inspection on 7/9/24 Licensee stated the sprinkler alarm had not been serviced for a few years and the smoke detectors were removed because they are too loud.

Based on observation & interview, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed staff using R1's room as common use to take trash to the outside bins.

Based on observation, interview, record review, the licensee did not comply with the section cited above ] which poses/posed a potential health, safety or personal rights risk to persons in care. Facility was not able to provide an emergency/disaster plan for the facility.

Based on observation, interview, & record review, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed Centrally Stored Medication Log to not be completed properly. Log did not have a start date.

Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed garage area used to store food needs to be clutter free in order to prevent pests. Outside refrigerator used to store resident's food needs to be cleaned.

Based on observation & interview, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. LPA observed an open package of bacon to be stored with a open package of sliced cheese (raw meat with dairy). Neither item was stored properly causing contamination.

Based on observation & interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed expired foods and food not labeled properly.

Based on observation, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. Garage area used to cook certain foods needs to be free from clutter, cleaned, and maintained. Dirty dishes and food not properly stored is left out which can attract rodents.

Based on observation & interview, the licensee did not comply with the section cited which poses an immediate health, safety or personal rights risk to persons in care. LPA observed garage door to be unlocked which had knives accessible to residents. One drawer in the kitchen was unlocked which had scissors accessible to residents.

Based on observation & interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed bleach and other cleaning products under an unlocked kitchen sink.

87625(b)(1)-Managed Incontinence-Requirements for Allowable Health Conditions, the licensee shall be responsible for the following: Ensuring that residents who can benefit from scheduled toileting are assisted or reminded to go to the bathroom at regular intervalsThis requirement is not met as evidenced by Based upon document review and interview: the Licensee failed to provide 1 of 1 residents with scheduled toileting or regular reminders. Instead staff would wait for a bell or to be called by R1 who had a diagnosis of dementia.This poses an immediate Health, Safety and/or Personal Rights risk to Residents in care.

1569.3129(e) Basic services requirementsEvery facility required to be licensed under this chapter shall provide at least the following basic services: Monitoring the activities of the residents while they are under the supervision of the facility to ensure their general health, safety, and well-being.This requirement is not met as evidenced by: Based upon document review and interview: the Licensee failed to provide 1 of 1 residents with supervision to ensure general health, safety and well being.This poses an immediate Health, Safety and/or Personal Rights risk to Residents in care.

87463(b) Reappraisals-The licensee shall immediately bring any such changes to the attention of the resident's physician and family or responsible person.This requirement is not met as evidenced by: Based upon document review and interview: the Licensee failed to immediatly notify 1 of 1 residents physician regarding R1's falls, increase in hallucinations, or R1 "acting/feeling out of sorts"This poses an immediate Health, Safety and/or Personal Rights risk to Residents in care.

1569.269(a)(1) Enumerated rights; severability-Residents of residential care facilities for the elderly shall have all of the following rights: To be accorded dignity in their personal relationships with staff,This requirement is not met as evidenced by:Based upon observation, document review and interview: the Licensee failed to treat 1 of 1 residents with dignity. R1 had a diagnosis of dementia and needed supervision and instead the licensee tied a bell to R1 and told her to summon for assistance to be toileted.This poses an immediate Health, Safety and/or Personal Rights risk to Residents in care.

87309 (a)- Storage Space-Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.This requirement is not met as evidenced By: Based upon observation the Licensee failed to keep disinfectans and cleaning solutions stored inaccessible to residents in careThis poses an immediate Health, Safety and/or Personal Rights risk to Residents in care.

87307-Personal Accommodations and Services-(d) The following space and safety provisions shall apply to all facilities:(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.This requirement is not met as evidenced by: Based upon observation the Licensee failed to keep both the exterior and interior passage way to an emergency exit free from obstructionThis poses an immediate Health, Safety and/or Personal Rights risk to Residents in care.

87465(h)(2)-Incidental Medical and Dental Care-following requirements shall apply to medications which are centrally stored:(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees. This requirement is not met as evidenced by: Based upon observation and interview the Licensee failed to keep medication centrally stored and locked so that it is no accessible to 5 of 5 residents in care.This poses an immediate Health, Safety and/or Personal Rights risk to Residents in care.