Shepherd Hills Senior Care LLC.

“Based on documentation review, record review, and interview when a resident reported exploitation to the facility, the manager failed to ensure a caregiver immediately reported the allegation to law enforcement or adult protective services, documented the suspected exploitation, documented an internal investigation within five working days. The deficient practice posed a risk as the Department was unable to assess if there was an immediate health and safety concern for residents who resided in the assisted living facility. Findings include: 1. A review of facility documentation revealed an incident report or investigation involving R1 was not available for review. 2. A review of R1's medical record revealed a service plan for personal care services. 3. In an interview, E1 reported Adult Protective Services had been to the facility two days prior to investigate exploitation and abuse of R1. E1 reported R1 had been saying their wedding ring was missing for about two weeks. E1 reported none of the staff had seen R1 with a wedding ring, and they called R1's representative who also had not seen R1 with a wedding ring. E1 reported R1 had been living independently, and was a hoarder. E1 reported R1 ended up in the hospital and was not able to return home. E1 reported R1's representative did not have regular contact with R1 prior to R1 being in the hospital. E1 reported some of R1's furniture and clothing was brought to the facility. E1 acknowledged it was possible R1 had lost a wedding ring. E1 reported R1 was initially classified as personal care, but they are now considering changing R1 to directed care due to a few incidents where R1 went into other resident's rooms to take their things, believing they were R1's belongings, and the other residents yelled at R1. E1 reported the alleged theft of the wedding ring and the other incidents involving R1 had not been reported or documented. 4. In an exit interview with E1, the findings were reviewed and no additional information was provided.”

“Based on record review and interview, the manager failed to ensure a medication administered to a resident was administered in compliance with a medication order, for one of two sampled residents. Findings include: 1. A review of R2's medical record revealed a service plan, dated May 16, 2025 for personal care services including medication administration. 2. A review of R2's medical record revealed an order, dated May 5, 2025, for "Carpidopa-levodopa (carpidopa-levodopa 10 mg-100 mg oral tablet), 2 tab, Tab, Oral TID, 180 tab, 0 refills, administered @ 0500, 1300, 2100." 3. A review of R2's medical record revealed a medication administration record, (MAR) dated June 2025. The MAR indicated, "Carbidopa/Levodopa 10mg/100mg, take two tabs PO TID," had been administered each day at 8 AM, 2 PM and 8 PM instead of the ordered eight hour interval of 5 AM, 1 PM and 9 PM. 4. In an interview, E1 acknowledged medication had not been administered to R2 in compliance with a medication order.”

“Based on observation and interview, the manager failed to ensure medication stored by the assisted living facility was stored in a separate locked self-contained unit used only for medication storage.   Findings include:   1. During an environmental tour of the facility, the Compliance Officers observed the office was unlocked, the door was open, and the office was unoccupied. Inside the office, the Compliance Officers observed a cabinet without a lock which contained resident medications.   2. During an interview, E1, acknowledged the medications were not stored in a locked manner and inaccessible to a resident.”

“Based on observation and interview, the manager failed to ensure poisonous or toxic materials stored by the assisted living facility were maintained in a locked area and were inaccessible to residents. Findings include: 1. During an environmental tour of the facility, the Compliance Officers observed a cabinet in the kitchen island which did not have a lock. Inside the cabinet, the Compliance Officers observed a spray bottle of "Sprayway Glass Cleaner." 2. In an interview, E1 acknowledged poisonous or toxic materials stored by the assisted living facility had not been maintained in a locked area inaccessible to residents.”

“Based on observation and interview, the manager failed to ensure hot water temperatures were maintained between 95º F and 120º F in areas of an assisted living facility used by residents. The deficient practice posed a risk to the physical health and safety of a resident. Findings include: 1. During an environmental tour of the facility, the Compliance Officers observed the water temperature in a common bathroom was 129º F. 2. In an interview, E1 acknowledged hot water temperatures were not maintained between 95º F and 120º F in areas of an assisted living facility used by residents. This is a repeat deficiency from the on-site compliance inspection conducted on June 12, 2024.”

“Based on observation and interview, the manager failed to ensure the hot water temperature was maintained between 95 \'b0F and 120 \'b0F in areas of the assisted living facility used by residents. Findings include: 1. During an environmental inspection of the facility, the Compliance Officer observed water temperature measured at 127.5\'b0 F in a shared resident bathroom. 2. In an interview, E1 acknowledged the hot water temperature had not been maintained between 95 \'b0F and 120 \'b0F in and area of the assisted living facility used by residents.”