Shepherd Homes 1

(a) ...residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:...(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.This requirement was not met as evidenced by: Based on interviews conducted and records reviewed the licensee did not adequately supervise R1 resulting in R1 wandering from the facility. This poses a potential health, safety and personal rights risk to residents in care.

Based on LPA observation, the licensee did not comply with the section cited above in LPA observed trash, unused bikes, vehicles, and children’s toys around the sides and backyard area of the facility which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPA observation the facility refrigerator has several containers without dates or labels which poses a potential health, safety risk to residents in care.

Based on observation, interview, and record review, the licensee did not comply with the section cited above in that observed MAR system in use but weekends in October not signed by facility staff, not documented when staff two (S2) was scheduled off. S2 stated medications are given but not signed off on MAR because other staff administer them but they do not write it down which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on observation, interview, and records review, the licensee did not comply with the section cited above that fire suppression system was last inspected in 3/2020 which poses an immediate health, safety or personal rights risk to persons in care.