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.

Based on record review, and interview, the governing authority failed to ensure compliance with Arizona Revised Statutes (A.R.S.) \'a7 36-411(G), for one of two employees sampled. A.R.S. \'a7 36-411(G) states: "G. If a person's employment record contains a six-month or longer time frame during which the person was not employed by any employer, a completed application with a new set of fingerprints shall be submitted to the department of public safety." Findings include: 1. A review of E3's personnel record revealed E3 had been hired in June of 2021 as a caregiver. 2. A review of E3's personnel record revealed a valid fingerprint clearance card issued in May of 2018. 3. a review of E3's personnel record revealed a job application which included a work history. The work history listed one prior employer and indicated E3 worked for that employer from "2013 to 2018." 4. A review of E3's personnel record revealed no documentation of E3's employment record between 2018 and June of 2021, a gap of more than six months during which time E3 was not documented to have been employed by any employer. However, documentation of E3 submitting a new set of fingerprints to the department of public safety was not available for review. 5. In an interview, E1 acknowledged the personnel record provided for E3 did not include documentation of compliance with A.R.S. \'a7 36-411(G).

Based on record review and interview, the manager failed to ensure documentation required by this Article was provided to the Department within two hours after a Department request. Findings include: 1. On June 5, 2023, the Compliance Officer requested the following document during the on-site inspection: - The annual review of the facility's disaster plan. However, this document was not provided for review. 2. In an interview, E1 acknowledged this documentation had not been provided for review. E1 reported the last annual review had been thinned from the binder and the new review had not been completed yet.

Based on record review, observation, and interview, the manager failed to ensure a medication was administered in compliance with a medication order, for two of two residents sampled. Findings include: 1. A review of R1's medical record revealed a service plan, updated March 15, 2023, for personal care services including medication administration. 2. A review of R1's medical record revealed a signed medication order dated January 3, 2023. This medication order included: - "Atorvastatin 80 mg, 1 tablet, PO, bedtime." 3. A review of R1's medical record revealed a signed medication order dated July 5, 2022. This medication order included: - "Atorvastatin 80 mg, 1 tablet, PO, daily (bedtime)." 4. A review of R1's medical record revealed a signed medication order dated February 23, 2021. This medication order included: - "Atorvastatin 40 MG, Give 1 tablet by mouth at bedtime for HLD." 5. A review of R1's medical record revealed a Medication Administration Record (MAR) dated June 2023. The MAR indicated the following: - R1 had received Atorvastatin, 40 milligrams, once daily on June 1 through June 4, 2023. 6. A review of R1's medical record revealed a Medication Administration Record (MAR) dated May 2023. The MAR indicated the following: - R1 had received Atorvastatin, 40 milligrams, once daily on May 1 through May 31, 2023. 7. A review of R1's medical record revealed a Medication Administration Record (MAR) dated April 2023. The MAR indicated the following: - R1 had received Atorvastatin, 40 milligrams, once daily on April 1 through April 30, 2023. 8. A review of R1's medical record revealed an order to decrease R1's Atorvastatin dosage from 80 milligrams to 40 milligrams was not available for review. 9. The Compliance Officer observed a mediset containing R1's medications included a 40 milligram Atorvastatin tablet in each evening section. 10. A review of R2's medical record revealed a service plan, updated February 9, 2023, for personal care services including medication administration. 11. A review of R2's medical record revealed a signed medication order dated March 17, 2023. This medication order included: - "Furosemide 20 mg, 1 tablet, PO, QD Edema." 12. A review of R2's medical record revealed a Medication Administration Record (MAR) dated June 2023. The MAR indicated the following: - R2 had received not received Furosemide, 20 milligrams, in June 2023. The MAR included an entry for the medications, however, the entry was marked, "PRN," and had not been administered. 13. A review of R2's medical record revealed an order to change R2's Furosemide schedule to as-needed was not available for review. 14. In an interview, E1 acknowledged medications had not been administered to R1 and to R2 in compliance with the orders provided for review. E1 reported both medications had been changed and were being administered correctly, but the change orders had not been obtained and filed. This is a repeat deficiency from the on-site compliance inspection condu

Based on observation and interview, the manager failed to ensure the disaster plan required in subsection (A)(1) was reviewed at least once every 12 months. The deficient practice posed a risk as a disaster plan reinforces and clarifies standards expected of employees, the Department was unable to determine substantial compliance during the inspection, and the documentation was not provided within two hours after a Department request. Findings include: 1. The Compliance Officer requested to review the facility's annual disaster plan review. However, the facility's annual disaster plan review was not provided for review. 2. In an interview, E1 acknowledged documentation of an annual review of the facility's disaster plan had not been provided for review within two hours after a Department request.