Good Shepherd Nursing Home

Inspectors wroteBased on record review and staff interviews the facility failed to provide an environment free from accident hazards by not assessing the need for hand rail assist bars. This failure created an immediate jeopardy situation and caused the entrapment of one resident who was found deceased with their head and arm between the hand rail and mattress. This failed practice had the potential to affect all residents residing in the long term care facility because all residents except one (1) have the bilateral hand rail assist bar. Resident identifier: #100. Facility census: 174. [...]

Inspectors wroteBased on staff interviews, observation and document reviews, the facility failed to complete an accurate bed rail assessment for a resident. The current assessment did not fully assess resident's risks/needs for side rails. This was true for Resident #100. and had the potential to affect more than a minimal number of residents residing in the long term care facility. Facility Census: 174.

Inspectors wroteBased on staff interview, resident interviews, and observation the facility failed to ensure residents knew they had the right to file grievances anonymously. This deficient practice had the potential to affect more than a limited number of residents. Facility Census:

Inspectors wroteBased on observation and staff interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible; and that the resident received adequate supervision and assistance devices to prevent accidents. Mounted wall heaters had maintenance access panel covers missing exposing thin sharp metal edges, wires and hot pipes in 3 (three) resident rooms. This failed practice was a random opportunity for discovery. Resident identifiers #58, #146, #33, and #74. Facility Census: 181. Findings Included:a) On 08/18/25 at 11:50 AM, during a facility entrance walkthrough it was observed that the wall mounted heater maintenance access panel covers were missing and exposing thin sharp metal edges, hot pipes, and wires in room [ROOM NUMBER], #343, and #347, where Resident #58, #146, #33, and #74 reside. [...]

Inspectors wroteBased on record review, staff interviews and resident interviews, the facility failed to ensure residents receive the help and care they need without waiting long periods of time. This deficient practice had the potential to affect more than a limited number of residents. Resident identifiers: #86, #181, #161, #23, #400, #19, #48, #86, #45, and #99. Facility Census: 181Findings included:a) On 08/18/25 at 2:53PM, In an interview with Resident #26, She stated on Sunday(08/19/25) she had to wait 45 minutes to get staff to take her to the restroom and stated she was going to soil herself. She said I know I wear briefs, but it is not comfortable to wet in them. I try not to if I can help it. She stated that long wait times often happen on the weekends and evening shifts but also sometimes on day shift as well. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure that the recommendations by the pharmacist were reviewed, addressed, responded to, and signed by the physician. Resident identifiers: #16, #1, #15, #23, and #19. Facility Census: 181. a) Resident #16 Resident #16's record review on 08/202/5 at 2:00 PM revealed the following recommendations: On 03/11/25 the Consulting Pharmacist stated: Patient has had significant weight loss. Recommend assessing for weight loss and the possible need for the initiation of medication to help with appetite. There was no review, or acknowledgement of the recommendation by the physician. The recommendation was unsigned. On 07/16/25 the Consulting Pharmacist noted: Patient has had several soft blood pressures located in their vital signs. Recommend adding monitoring/hold parameters for BP (blood pressure) medications. [...]

Inspectors wroteBased on observation and staff interviews, the facility failed to store food in a safe sanitary manner in regard to expired milk and storing medical supplies in the freezer in the resident's pantry. This has the potential to affect more than a limited number of residents. Facility census: 181. Findings Included: a) Kitchen During the initial kitchen tour on 08/21/25 at 11:35 AM observations found: Walk-in refrigerator -found 4 half gallons of milk expired. During an interview on 08/21/25 at 11:40 a.m., the Dietary manager confirmed the milk was expired. During the tour on 08/18/25 at 11:45 AM of the resident pantries found medical Ice packs stored in resident freezers in four (4) of five (5) pantries. An interview on 08/18/25 at 11:45 AM with the Dietary Manager confirmed the medical ice packs should not be stored with resident food.

Inspectors wroteBased on record review, facility policy review and interview, the facility failed to have a water management plan that followed nationally accepted standards (CDC), and incorporated measures to control and prevent Legionella and other opportunistic waterborne pathogens. Facility Census: 181. Findings Include:a) During an interview on 08/19/25 at approximately 11:13 AM the Maintenance Director (MD) #130 provided legionella testing results for four (4) different locations around the facility. The results were negative. Monthly temperature logs were reviewed. MD #130 provided monthly flushing and disinfection logs for dead ends and unused rooms, equipment and showers, verifying that the facility performed control measures, such as flushing and draining dead ends, and unused showers. MD #130 stated that there had been no outbreaks of Legionella or other waterborne infections. [...]

Inspectors wroteBased on observation and interview, the facility failed to promote the resident's right to a dignified existence. Resident #41 was observed in the hallway in only his brief. This was a random opportunity for discovery. Resident Identifier #41. Facility census: 181. Findings Include: a) Resident #41On 08/20/25, at approximately 9:31 AM, Resident #41 was observed in a wheelchair outside his room, wearing only a brief. He was clearly visible to staff and other residents walking down the hallway. Staff members were seen passing by the resident without expressing any concern about his attire. This concern was brought to the attention of Licensed Practical Nurse (LPN) #24, who responded, I don't know why he hasn't been dressed yet! LPN #24 then went directly to the resident and wheeled him back to his room. She was observed to instruct a Nursing Assistant (NA) to help Resident #41 get dressed. [...]

Inspectors wroteBased on observation and staff interviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for room [ROOM NUMBER] and #340. This failed practice was a random opportunity for discovery. Facility Census: 181.

Inspectors wroteBased on record review and interview, the facility failed to notify the Office of the Long-Term-Care Ombudsman of the resident's discharge from the facility. Resident Identifier: #188. Facility Census: 181. Findings Include:a) Resident #188The resident was no longer at the facility. A closed record review performed on 08/20/25 at 9:30 AM revealed that the resident was transferred to the hospital on [DATE]. Record review revealed that the resident's Power of Attorney (POA) was notified on 05/24/25. During an interview with Social Worker #183 on 08/20/25, at approximately 1:20 PM, she presented a document that verified the notification of the resident's family members and the responsible party. When asked whether the Ombudsman had been notified, SW #183 indicated that she would need to check for that information. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to update the PASARR for Resident #19, after the resident was diagnosed with a major mental disorder after admission to the facility. This was true for one (1) of four (4) residents reviewed for PASARR during the survey process. Resident Identifier: 19. Facility census: 181. a) Resident #19On 08/21/25, a record review of the resident's electronic medical record (EMR), the resident's admission PASARR, dated 08/31/23, indicated no level II was needed. Section lll #30 MI/MR Assessment indicated Other developmental disabilities. A continued record also revealed Resident#19 received a diagnosis of Paranoid Schizophrenia on the diagnosis listed after admission on [DATE] but did not receive a new PAS to address whether specialized services were needed. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure the clarification of a resident's medication order for a drug that was required to be taken with food h. This was a random opportunity for discovery. Resident Identifier #40. Facility Census: 181. Findings Include: a) Resident #40 Record review on 08/20/25 at 8:59 AM revealed that Resident #40 had the following order dated 05/01/25, prescribed by her physician:Sensipar Oral Tablet 30 MG (Cinacalcet HCl)Give 1 tablet by mouth one time a day for elevated calciumThe United States Food and Drug Administration (FDA) guidelines state the following for administration of Cinacalcet (Sensipar):For all indications, Cinacalcet (Sensipar) should be taken with food or shortly after a meal and should always be taken whole and not divided. [...]

Inspectors wroteBased on record reviews and interviews, the facility failed to follow weight policy and ensure resident weight was accurate and if needed a re weight preformed. Resident #51's weights were not rechecked per policy. This was a random discovery during the survey process and had the potential to effect more then a limited number of residents. Resident identifier: #51. Facility census: 181 a) Resident #51Resident #51 had five weights entered into the charting that should have triggered a re-weigh on that same day, as well as notification to the Medical Doctor. The facility failed to preform the re-weigh or notify the MD per facility policy. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure that the recommendations by the pharmacist were reviewed, addressed, and responded to, by the physician. This effected 2 out of 4 residents sampled. Resident Identifier 23 and 1. Census:181 The facility FAILED TO MEET STANDARD as evidenced by:The facility failed to ensure the pharmacist recommendations where address by the physician to ensure medication need or adjustment for residents #1 and #23. There were no copies of the recommendations in the electronic charts, the hard copies had the recommendations in them, but were unsigned by MD for the last two months. Resident (1) Record Review: 08/20/2025 MRR - was not signed into the resident's chart. There was not an electronic or hard copyMissing signature of MD on last two MRR's dated 7/31/25 & 6/30/25 Had sign here tags in place for MDInterview: [...]

Inspectors wroteBased on medical record review, policy review, resident interview and staff interview, the facility failed to ensure the residents had the right to participate and must be given the opportunity to participate in development, review and revision of his/her care plan. This was true for four (4) of 36 reviewed for care plans during the Long-Term Care Survey Process. Resident identifiers: Resident #6, Resident #158, Resident #116 and Resident #43. Facility census: 118.

Inspectors wroteBased on observation, policy review, medical record review, resident interview and staff interview, the facility failed to implement an ongoing resident centered activities program designed to meet the interest of and support the physical, mental and psychosocial well-being of each resident. This practice was found for four (4) of four (4) Residents reviewed for the Activity Care Area during the Long term care survey process. Resident identifiers: #6, #36, #1 and #72. Facility census: 181.

Inspectors wroteBased on record review and staff interview, the facility failed to manage pain in accordance with professional standards of practice for one (1) of six (6) residents reviewed for the care area of pain. Resident identifier: #51. Facility census: 181.

Inspectors wroteBased on record review and staff interview, the facility failed to provide Notice of Discharge to the Office of the State Long Term Care (LTC) Ombudsman during a discharge/transfer. This was true for one (1) of one (1) residents reviewed for hospitalization. Resident identifier #178. Facility census 181.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the residents Preadmission Screening and Resident Review (PASRR) reflected the admission diagnosis. This was true for three (3) of five (5) reviewed for the PASRR care area during the Long-Term Care Survey. Resident identifiers: Resident #30, Resident #76, Resident #8. Facility census: 181.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice by failing to comply with physician's orders. This deficient practice had the potential to affect three (3) of 36 residents reviewed in the long-term care survey sample. Resident identifiers: #60, #43, and #158. Facility census: 181.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to ensure wander guard devices were properly maintained to prevent elopement hazards. This failed practice was true for one (1) of two (2) Residents reviewed for elopement. Resident identifier: #151. Facility census: 181.

Inspectors wroteBased on record review and staff interview, the facility failed to maintain an accurate and correct medical record. This was discovered for one (1) of 36 residents reviewed for the area of advance directives. Resident #175 did not have an order for hospice services and the Do Not Resuscitate (DNR) order was incomplete. Resident identifier: #175 Facility census: 181.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections. Appropriate hand hygiene was not performed during the pressure ulcer dressing change for one (1) of one (1) pressure ulcer dressing change observations. Resident identifier: #60. Facility census: 181.

Inspectors wroteBased on record review and staff interview, the facility failed to document that vaccination education was provided to residents receiving influenza vaccination. This failed practice had the potential to affect three (3) of five (5) residents reviewed for the care area of immunizations. Resident identifiers: #60, #97, and #30. Facility census: 181.

Inspectors wroteBased on observation and staff interview, the facility failed to display the staffing posting in a prominent place readily accessible to residents and visitors. This was a random opportunity for discovery. Facility census: 178.

Inspectors wroteBased on observation of medication administration, staff interview, and record review, the facility failed to ensure the facility's medication error rate was less than five (5) percent. Facility staff failed to administer medications according to professional standards for two (2) residents during medication administration contributing to a 10.53 % medication error rate. This deficient practice was a random opportunity for discovery and had the potential to affect more than a limited number of residents. Resident identifiers: Resident # 123 and #89 Census:

Inspectors wroteBased on policy review, observation, medical record review, and staff interview, the facility failed to establish and maintain an infection prevention program to help prevent the development and transmission of communicable diseases and infections including Covid-19 and influenza in regard to precaution signage at resident doors, medication pass, and dietary services. These practices had the potential to affect more than a limited number of residents residing in the facility. Resident identifiers: Resident identifiers: #128, #105, #35 and #84. Room identifier: #224. Facility census: 178.

Inspectors wroteBased on record review and staff interview, the facility failed to revise a care plan when the resident required increased assistance with meals. Resident identifier: #21. Facility census: 178.

Inspectors wroteBased on observations and staff interview, the facility failed to meet professional standards of quality when a non-crushable medication was crushed and administered to Resident #142. In addition, the facility failed to ensure Resident #89 had been assessed and approved by the physician to self administer two (2) inhalers. This was a random opportunity for discovery. Resident identifiers: #89 and #142. Facility census: 178.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to ensure one (1) of 35 sampled residents reviewed, received treatment and care in accordance with physician's orders. The facility failed to ensure physician's orders were implemented for Resident # 217. Resident identifier: Resident #217. Facility census: 178.

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to provide necessary treatment and services to promote healing of pressure ulcers. This was true for one (1) of six (6) residents reviewed for pressure ulcers. Resident identifier: #103. Facility census 178.

Inspectors wroteBased on observation, medical record review, and interview, the facility failed to deliver respiratory care services consistent with professional standards of practice. Oxygen supplies were not stored safely or properly for residents reviewed during the Long-Term Care Survey Process (LTCSP). This was a random opportunity for discovery. Resident identifier: #376. Facility census: 178.

Inspectors wroteBased on record review, staff interview, and policy review, the pharmacist failed to identify irregularities for medications in excessive doses related to Acetaminophen (Tylenol). This was true for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifier: #16. Facility census: 178.