Good Shepherd Health Center

Inspectors wroteBased on observation, clinical record review, facility policy review, family, and staff interviews the facility failed to do a timely assessment on 1 of 3 residents reviewed (Resident #1). Resident #1 had a bruise on the right inner/outer thigh and hip area. The facility staff knew about the bruise on 2/13/26, and 2/14/26, which no staff assessed the area until 2/15/26 when the resident started to complain of pain. The facility reported a census of 150 residents.

Inspectors wroteBased on observation, clinical record review, staff interviews, and facility policy and procedures, the facility failed to implement interventions to prevent weight loss and implement adequate hydration for 1 of 3 residents reviewed for weight loss and hydration (Resident #2). The facility identified a census of 150 residents.

Inspectors wroteBased on observation, record review, and staff interviews the facility failed to ensure the windows for 2 of 2 bird aviaries were maintained in between routine cleanings and kept free of excessive bird feces. The facility reported a census of 145 residents.

Inspectors wroteBased on record review, staff interview, and policy review the facility failed to ensure the Medical Director attended the Quality Assessment and Assurance (QAA) meetings quarterly. The facility reported a census of 145 residents.

Inspectors wroteBased on record review, staff interview and policy review, the facility failed to notify resident's representative in advance of the risks and benefits of a psychotropic medication, the treatment alternatives or other options and was able to choose the option the representative prefers for 1 of 5 residents reviewed (Resident #1). The facility reported a census of 145 residents.

Inspectors wroteBased on record review, staff and family interviews, and policy review the facility failed to ensure 1 of 2 residents personal belongings were retained in the facility and returned to the family after their death (Resident #159). The facility reported a census of 145 residents. Facility staff implemented immediate interventions on [DATE] and completed on [DATE] through the following actions:a. Discussion with facility staff on where the missing items went and identifying a miscommunication occurred with facility staff.b. Offered the family to replace the items at the facilities expense. The deficient practice was identified as past non-compliance singular event as of [DATE], the items were thrown away due to miscommunication prior to the survey, and financial compensation was offered to the family.

Inspectors wroteBased on clinical record review, staff interview and policy review, the facility failed to submit a Preadmission Screening and Resident Review (PASRR) for 1 of 2 residents with new mental health diagnoses (Resident #22). The facility reported a census of 145 residents.

Inspectors wroteBased on observation, clinical record review, staff interview, and facility policy/procedure review at the time of the investigation, the facility failed to intervene timely for a resident who needed had a change in condition following a fall on 2/3/25 for 1 of 4 residents reviewed (Resident #2). At Resident #2's admission in December 2024, he came to the facility with a repaired fractured right hip due to a fall at home. Due to his cognition, he frequently forgot he previously had a hip fracture and would frequently transfer by himself. On 2/3/25, he had an unwitnessed fall. When the nurse assessed him, he reported pain to his right hip. After the nurse's assessment, 2 Certified Nurse Aides (CNAs) assisted Resident #2 from the floor and back into bed. Despite Resident #2's recent surgical repair of his right hip, the nurse faxed the physician instead of sending him for evaluation. [...]

Inspectors wroteBased on clinical record review, policy/procedure review, and staff interview the facility failed to treat a resident with respect and dignity in a manner that promotes maintenance or enhancement of his or her quality of life for 1 out of 3 resident reviewed. (Resident #2). The facility identified a census of 151 residents.

Inspectors wroteBased on clinical record review, Resident [NAME] of Rights, facility investigation, staff interview, and review of policy and procedures, the facility failed to report an allegation of abuse to the Department of Inspection and Appeals and Licensing (DIAL) for 1 of 3 residents reviewed (Resident #2) within the required 2-hour timeframe. Staff A, Certified Nurse Aide (CNA), alleged the witnessed Staff B, CNA, hit Resident #2 on 3/7/25. Staff A failed to report the incident to the facility until 3/8/25, after the 2-hour window when they witnessed the alleged incident. The facility reported a census of 151 residents.

Inspectors wroteBased on clinical record view, staff interview, and the Resident Assessment Instrument (RAI) Manual, the facility failed to transmit 1 of 1 Minimum Data Set (MDS) assessments for the facility within the required timeframe (Resident #34). The facility reported a census of 159 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to reassess blood pressures for one of one resident reviewed (Resident #67). Resident #67 had high and low blood pressures that didn't get reassessed. The facility reported a census of 159.

Inspectors wroteBased on observation, clinical record review and staff interview, the facility failed to provide services to treat or prevent reduction in range of motion for 1 of 1 resident sampled (Resident #134). After finishing Occupational Therapy, Resident #134 received specially modified palm guards to protect her hand from her contractures. Multiple observations revealed Resident #134 didn't have palm guards. Interviews determined, she didn't have them for a while and no one contacted therapy about getting replacements. The facility identified a census of 159 residents.

Inspectors wroteBased on record review, observation, policy review, staff, and resident interviews, the facility failed to ensure a resident had their call light within reach at all times for 1 of 3 residents reviewed for recent falls (Resident #17). The facility reported a census of 159 residents.

Inspectors wroteBased on record review, resident, and staff interviews the facility failed to catheterize residents only when they had an order for 1 of 1 resident reviewed (Resident #46). The facility reported a census of 159 residents.

Inspectors wroteBased on record review and staff interviews the facility failed to ensure the Facility Assessment evaluated each resident's need for activities of daily living (ADL's), bowel, bladder, mental ability, skin integrity, special care, treatment, and medications. In addition, the facility failed to evaluate their ability to meet their needs. The facility reported a census of 159.

Inspectors wroteBased on observation, clinical record review, policy review, and staff interview, the facility failed to implement adequate infection control prevention practices. While passing medication to a resident, the Certified Medication touched the resident's medication with their bare hands for 2 of 4 resident observed (Residents #213 and #26). The facility identified a census of 159 residents.

Inspectors wroteBased on record review, staff interviews, and policy review the facility failed to ensure 1 of 3 residents (Resident #1) did not fall when getting off of the facility van. The facility reported a census of 153 residents.

Inspectors wroteBased on observation, clinical record review, facility policy review, family, physician, emergency medical personnel, and staff interview, the facility failed to implement interventions in a timely manner for a resident following a fall for 1 of 3 residents reviewed (Resident #3). The facility failed to intervene after Resident #3 fell and complained instantly of new pain to his ribs. Despite, the family's frequent questioning about Resident #3's situation, the facility failed to send him to the hospital for 2 hours and 36 minutes following his fall. The facility's policy requires someone from nursing management to assess a resident following an incident. It took the nursing supervisor approximately 1 hours after Resident #3 fell for the nursing supervisor assessed Resident #3. [...]

Inspectors wroteBased on observation, resident, and family interview, the facility failed to answer resident call lights in a timely manner and within the regulated 15-minute time frame for 3 of 5 residents reviewed (Resident #3, #4 and #5). The facility reported a census of 165 residents.

Inspectors wroteBased on observation, family interview and review of the Resident Rights the facility staff failed to treat a resident with dignity and respect while providing cares and treatment while speaking with the resident and/or the family member present at bedside for 1 of 3 residents reviewed (Resident #4). The facility reported a census of 165 residents.

Inspectors wroteBased on observation, record review, staff interviews, and facility policy review the facility failed to provide adequate nursing supervision to prevent resident's with severe cognitive impairment from engaging in sexual contact for 2 of 4 residents reviewed.

Inspectors wroteBased on observation, interview, and document review, the facility failed to post daily staffing in a clear and readable format and in a prominent place readily accessible to residents and visitors. The facility also failed to include the daily census on the posting.

Inspectors wroteBased on observation and interview, the facility failed to ensure garbage was properly disposed of and contained which would affect all the residents and staff in the facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure one of one resident (Resident (R) 149), reviewed for not having a Minimum Data Set (MDS) in over 120 days, had a discharge assessment transmitted to Centers for Medicaid and Medicare Services (CMS) in a timely manner. This failure has the potential to have Medicare or Medicaid services denied due to the payment system having the R149 as being a nursing facility resident.

Inspectors wroteBased on record review and interview, the facility failed to accurately assess two of four residents (Resident (R) 155 and R158) reviewed for hospice on the Minimum Data Set (MDS) assessment tool. This failure had the potential to affect the resident's Medicare hospice benefit and care planning coordination between the facility and hospice provider.

Inspectors wroteBased observations, interviews, and record review, the facility failed to ensure that one resident (Resident (R) 20) received treatments for dandruff with a prescribed shampoo regimen out of a total sample of 33 residents. This failed practice hindered this resident's dandruff from getting better.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly document the need and removal of a wander guard for one resident (Resident (R) 83) out of four residents reviewed for unsafe wandering and elopement out of a total of 33 sampled residents.