Good Shepherd Care Center

Inspectors wroteBased on interview and record review, facility staff failed to designate a person to serve as the Director of Food and Nutrition Services with the appropriate qualifications, when the facility did not employ a qualified dietitian or other clinically qualified nutrition professional full-time. The facility census was 51. 1. Review of the facility's Dining Services Manager Roles and Responsibilities policy, dated 2020, showed the policy directed for the dining services manager to comply with current public health and safety standards in all phases of the department's operation. Review showed the policy did not contain information related to the education and experience requirements for the dining services manager. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to store food in a manner to prevent contamination and outdated used. The facility staff failed to perform hand hygiene as often as necessary using approved techniques to prevent cross-contamination. The facility staff failed to maintain the kitchen floors clean and in good repair to prevent the growth and harborage of bacteria. The facility staff also failed to ensure the ice machine, used to supply ice to residents, drained through an air gap to prevent cross-contamination. The facility census was 51. 1. Review of the facility's Food Storage (Dry, Refrigerated, and Frozen) policy, dated 2020, showed: -Food shall be stored on shelves in a clean, dry area free from contaminants. Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety; [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to complete neurological assessments (evaluation completed by staff for early detection of nervous system damage following head trauma) for four cognitively impaired residents (Resident #11, #36, #39 and #41) after unwitnessed falls. The facility census was 51. 1. Review of the facility's policies showed staff did not provide a post fall policy for cognitively impaired residents. Review of the facility's Neurological Assessment Flow Sheet, showed neurological assessments are to be completed as followed: -Every 15 minutes for four times; -Every 30 minutes for two times; -Every 1 hour for two times; -Every 2 hours for two times; -Every 4 hours for two times; -Every 8 hours for four times. 2. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to accurately complete entrapment assessments for the use of bed rails for five residents (Resident #3, #6, #7, #27 and #30). The facility census was 51. 1. Review of facility's policies showed staff did not provide a bed rail policy. 2. Review of Resident #3's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 10/05/23, showed staff assessed the resident as: -Cognitively intact; -Required full dependence for bed mobility; -Bed rails not used. Review of the resident's electronic medical record (EMR), showed the record did not contain documentation staff completed: -Entrapment assessment; -Bedrail assessment; -Obtained consent. Observation on 02/13/24 at 10:40 A.M., showed the resident in bed with bilateral round mobility bars in the upright position. [...]

Inspectors wroteBased on interview and record review, facility staff failed to ensure two residents (Resident #18 and #44) have appropriate access to their trust fund account to include on the weekends. The facility census was 51. 1. Review of facility policies showed the facility did not have a policvy for availability of funds. 2. Review of Resident #18's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 11/3/23, showed staff assessed the resident as cognitively intact. During an interview on 02/15/24 at 1:30 P.M., the resident said, We don't have anyone at the facility on the weekend to give us money. The resident said he/she did not know what they would do if they needed money on the weekend. 3. Review of Resident #44's Quarterly MDS, dated [DATE], showed staff assessed the resident as cognitively intact. [...]

Inspectors wroteBased on observation, interview and record review, the facility staff failed to store food in a manner to prevent potential contamination and out-dated use. Facility staff failed to use food in a first in-first out method when facility staff opened multiple containers of the same food item for use. Facility staff also failed to maintain food storage equipment clean and in good repair. The facility census was 61. 1. Review of the facility's Food Storage (Dry, Refrigerated, and Frozen) policy, dated 2020, showed: -Food shall be stored on shelves in a clean, dry area free from contaminants. Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. -All food items will be labeled. The label must include the name of the food and the date by which it should be sold, consumed, or discarded. [...]

Inspectors wroteBased on staff interview and record review, the facility failed to electronically transmit quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by the facility) assessments in a timely manner and in accordance with guidelines for three residents (Residents #5, #44, and #51). The facility census was 61. 1. Review of the MDS 3.0 Resident Assessment Instrument (RAI) User's Manual, Version 1.17.1 dated October 2019 showed the following: -An Omnibus Budget Reconciliation Act of 1987 (OBRA) assessment (comprehensive or quarterly) is due every quarter unless the resident is no longer in the facility. There must be no more than 92 days between OBRA assessments; -Comprehensive assessments must be transmitted electronically within 14 days of the Care Plan Completion Date (V0200C2 + 14 days). [...]

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to provide safe mechanical lift transfers for four residents (Resident #3, #10, #12, and #16) in a manner to prevent accidents. Additionally, staff failed to safely store medications by leaving the medication cart unlocked and unattended. The facility census was 61. 1. Review of the facility's Storage of Medications policy, revised April 2019, directed staff to do the following: - The facility stores all drugs and biologicals in a safe, secure, and orderly manner; - Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls; - The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner; [...]

Inspectors wroteBased on observation, staff interview and record review, facility staff failed to ensure medication regimens were free from unnecessary medications when staff failed to obtain an appropriate diagnosis for the use of psychotropic medications (a chemical substance that changes brain function and results in alterations in perception, mood, consciousness or behavior) for three residents (Residents #11, #19 and #27). The facility census was 61. Review of American Geriatrics Society (AGS) 2019 Updated AGS Beers Criteria for Potentially Inappropriate Medication Use in Older Adults showed: -Avoid antipsychotics for behavioral problems of dementia or delirium unless nonpharmacological options (eg, behavioral interventions) have failed or are not possible and the older adult is threatening substantial harm to self or others. [...]

Inspectors wroteBased on observation, staff interview, and record review, facility staff failed to post the required nurse staffing information, which included the total number of staff and the actual hours worked, by both licensed and unlicensed nursing staff directly responsible for resident care, per shift, and on a daily basis. The facility staff also failed to keep the required daily staffing records for eighteen months. The facility census was 61. 1. Review of the facility's Posting Direct Care Daily Staffing Numbers, revised July 2016, showed the following: -Our facility will post, on a daily basis for each shift, the number of nursing personnel responsible for providing direct care to residents; [...]