Good Shepherd Services Ltd

Inspectors wroteBased on staff interview and record review, the facility failed to develop and/or implement policies and procedures for ensuring the reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Act when an allegation of sexual abuse was not reported to local law enforcement or the State Agency (SA) for 1 resident (R) (R1) of 3 sampled residents. On 4/15/26, R1 reported to Certified Nursing Assistant (CNA)-C that R1 was raped. Later that morning, R1 stated R1 was raped to Activities Director (AD)-D and Director of Nursing (DON)-B. The facility did not report the allegation of abuse to local law enforcement or the SA.

Inspectors wroteBased on staff interview and record review, the facility did not ensure an allegation of abuse was thoroughly and accurately investigated for 1 resident (R) (R1) of 3 sampled residents. On 4/15/26, R1 reported to Certified Nursing Assistant (CNA)-C that R1 was raped. Later that morning, R1 stated R1 was raped to Activities Director (AD)-D and Director of Nursing (DON)-B. The facility did not ensure the allegation of abuse was thoroughly and accurately investigated

Inspectors wroteBased on staff interview and record review, the facility failed to protect 3 residents (R) (R1, R2, and R4) of 12 sampled residents from physical abuse. On 12/4/25, R1 accused R2 of being in R1's home and aggressively grabbed R2's right wrist and squeezed it. R2 had bruising on the right hand and wrist. R1 had a bruise and skin tear on the left hand. On 12/9/25, R1 stuck R1's leg out to trip R4 and grabbed R4's right hand/wrist. R4 had two bruises on the right hand.

Inspectors wroteBased on staff interview and record review, the facility failed to ensure 1 resident (R) (R5) of 12 sampled residents was free from misappropriation of property. R5 reported to staff on [DATE] that on the morning of [DATE], R5 and R5's responsible party (child) noticed $276.00, a McDonald's gift card, and a Starbucks gift card were missing from R5's walker. An agency staff admitted to taking the money and gift cards.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection. This practice had the potential to affect more than 4 of the 31 residents residing in the facility. The facility did not have a detailed flow diagram of the facility's water system that identified areas where Legionella could grow. The facility's infection control policies were incomplete and/or did not contain current information. R17 was on EBP due to the presence of non-intact skin after R17's percutaneous endoscopic gastrostomy (PEG) tube (feeding tube via stomach) was removed. Certified Nursing Assistant (CNA)-G and CNA-H did not wear personal protective equipment (PPE) during high-contact resident cares, including changing linens and shaving R17. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure 3 residents (R) (R6, R27, and R7) of 5 sampled residents had documentation that indicated the residents or their legal representatives were thoroughly informed in advance of the risks and benefits of prescribed psychotropic medication. R6 was prescribed diazepam (a benzodiazepine medication) for a diagnosis of anxiety. The facility did not obtain written consent from R6 for the medication. R27 was prescribed olanzapine (an antipsychotic medication) for nausea and vomiting. The facility did not ensure a written consent form was thoroughly reviewed and completed with R27's Power of Attorney for Healthcare (POAHC). R7 was prescribed lorazepam (an antianxiety medication), buspirone (an anxiolytic medication), and duloxetine (an antidepressant medication). [...]

Inspectors wroteBased on staff and resident interview and record review, the facility did not ensure 2 residents (R) (R6 and R17) of 3 residents reviewed for hospitalization received the proper notice of transfer, reason for transfer, location of transfer, appeal rights, name and address with telephone number of the Office of the State Long-Term Care Ombudsman plus notification of discharges/transfers to the Ombudsman. In addition, the facility did not ensure R6 and R17 received written information on the duration of the bed hold policy, the reserve bed payment policy, and the right to return to the facility. R6 was transferred to the Emergency Department (ED) on 5/16/25. R6 was not provided with a written transfer or bed hold notice. In addition, the facility did not notify the Ombudsman of R6's transfer. R17 was transferred to the hospital on 2/14/25. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure a care plan was revised for 1 resident (R) (R4) of 12 sampled residents. The facility did not revise R4's care plan to include a chronic wound that reopened on 5/25/25. R4's care plan also did not indicate R4 was on enhanced barrier precautions (EBP).

Inspectors wrote2. From 5/27/25 to 5/29/25, Surveyor reviewed R27's medical record. R27 was admitted to the facility on [DATE] and had diagnoses including dementia with malignant neoplasm of the lung. R27's MDS assessment, dated 5/7/25, had a BIMS score of 5 out of 15 which indicated R27 had severe cognitive impairment. R27 had an activated Power of Attorney (POA). A care plan (initiated 1/31/25) indicated R27 was at high risk for falls. R27's medical record indicated R27 fell on 5/11/25, 5/15/25, and 5/18/25 with no noted injuries. R27's care plan did not contain new interventions following the falls. A fall risk assessment, dated 5/19/25, indicated R27 was a high fall risk. On 5/29/25 at 1:33 PM, Surveyor interviewed NHA-A who indicated R27 should have had a new fall intervention added to R27's care plan following each fall. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility did not provide the necessary respiratory care and services for 1 resident (R) (R21) of 2 sampled residents. R21's oxygen was not turned on per R21's continuous oxygen order.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the minimum required members of the facility's Quality Assessment and Assurance (QAA) committee met at least quarterly. This practice had the potential to affect all 31 residents residing in the facility. The facility did not have documentation that the minimum required members of the QAA committee met for quality assessment and assurance purposes on a quarterly basis.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not provide appropriate care and services for 1 resident (R) (R28) of 1 sampled resident with an indwelling catheter. On 4/10/24, Surveyor observed R28's catheter drainage bag in direct contact with a floor mat without a barrier to prevent infection.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure an injury of unknown origin was thoroughly investigated for 1 Resident (R) (R25) of 2 residents reviewed. The facility reported to the State Agency a concern involving a suspicious bruise on R25's face. The facility did not conduct a thorough investigation of the incident to rule out caregiver misconduct, did not re-educate staff on safety needs for R25 and did not update R25's care plan to help prevent the chance of further injury.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure staff performed proper hand hygiene for 2 Residents (R) (R16 and R25) of 4 residents observed during the provision of cares. Certified Nursing Assistant (CNA)-F and CNA-G did not consistently perform appropriate hand hygiene during the provision of perineal care for R16. CNA-E did not consistently perform appropriate hand hygiene during the provision of perineal care for R25.