The Shepherd's Center

Inspectors wroteThe facility reported a census of 20 residents. Based on interview and record review, the facility failed to ensure complete the required annual evaluation for two of the five Certified Nursing Aide staff sampled.

Inspectors wroteThe facility reported a census of 20 resident. Based interviews. the facility failed to employ a full-time certified dietary manager for the residents who resided in the facility and received meals from the facility kitchen.

Inspectors wroteThe facility reported a census of 20 resident with two satellite kitchens. Based on observation and interview the facility failed to prepare and serve food under sanitary condition to prevent the potential for food borne bacteria. This place the residents at risk for food borne illnesses.

Inspectors wroteThe facility identified a census of 20 residents. The sample included 13 residents. Based on observations, interview and record reviews, the facility failed to conduct a thorough facility wide assessment to determine the resources necessary to care for the residents competently during both day-day operations and emergencies. This failure affected all 20 residents residing in the facility.

Inspectors wroteThe facility reported a census of 20 residents; the sample included 13 residents. Based on interview and record review, the facility failed to complete a Quality Assurance and Performance Improvement Program (PIP) based on identification, investigation, analysis, and prevention of adverse events in the facility within the past year.

Inspectors wroteThe facility reported a census of 20 residents. Based on interview and record review the facility failed to complete a system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility. Additionally, the facility failed to complete a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents. This failure has the potential to affect all 20 residents.

Inspectors wroteThe facility reported a census of 20 residents; the sample included 13. Based on interview and record review the facility failed to ensure staff adhered to the principles of antibiotic stewardship through monitoring for the appropriate use of antibiotics prescribed to prevent antibiotic resistance and spread of multidrug resistant organisms within the facility.

Inspectors wroteThe facility reported a census of 20 residents; the sample included 13 residents. Based on interview and record review, the facility failed to complete a comprehensive Minimum Data Set (MDS) assessment in a timely manner for six residents; Resident (R)1, R2, R5, R14, R18, and R20.

Inspectors wroteThe facility reported a census of 20 residents. The sample included 13 residents with one resident reviewed for discharge. Based on interview and record review, the facility failed to provide Resident (R) 28 a written notification of discharge to the resident and/or his representative as soon as practicable and failed to complete a recapitulation of R28's stay.

Inspectors wroteThe facility had a census of 20 residents. The sample included 13 residents. Based on observation, interview, and record review, the facility failed to accurately complete the Minimum Data Set (MDS) for one resident. Resident (R) 10, related to psychotropic (alters mood or thought) medications.

Inspectors wroteThe facility reported a census of 20 residents; the sample included 13 residents. Based on observations, record review and interviews the facility failed to develop a Baseline Care Plan for Resident (R) 14.

Inspectors wroteThe facility reported a census of 20 residents; the sample included 13 residents. Based on observations, record review and interviews the facility failed to develop a comprehensive care for Resident (R)14.

Inspectors wroteThe facility reported a census of 20 residents, The sample included 13 residents. Based on observation, record review and interview the facility failed to revise the care plan for Resident (R) 6 regarding pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) .

Inspectors wroteThe facility reported a census of 25 residents. The sample included six residents reviewed for misappropriation and exploitation. Based on interview and record review, the facility failed to ensure the timely reporting of alleged exploitation to the State Agency (SA- a state governmental agency that provides oversight for the Centers for Medicare & Medicaid Services [CMS - the federal government agency that administers the nation's major healthcare programs]) or local law enforcement, as required, when the facility failed to report the allegation of exploitation of Resident (R) when Housekeeping Staff D coerced the resident to write her a check for $300.00. This deficient practice placed R1and other residents of the facility in immediate jeopardy with the risk for a negative psychosocial impact in safety and security.

Inspectors wroteThe facility reported a census of 25 residents. The sample included six residents reviewed for misappropriation and exploitation. Based on interview and record review, the facility failed to thoroughly investigate incidents of misappropriation of funds and failed to protect the residents from further misappropriation when Housekeeping Staff D coerced Resident (R)1 to write her a check for $300.00. This deficient practice placed R1and other residents of the facility in immediate jeopardy and placed the residents at risk for further misappropriation of funds.

Inspectors wroteThe facility reported a census of 25 residents. The sample included six residents reviewed for misappropriation and exploitation. Based on interview and record review, the facility failed to ensure Resident (R)1 remained free from misappropriation of funds, when Housekeeping Staff D coerced the resident to write her a check for $300.00. This deficient practice placed R1and other residents of the facility in immediate jeopardy with the risk for a negative psychosocial impact in safety and security.

Inspectors wroteThe facility reported a census of 22 residents with two separate units and two resident kitchens. Based on observation, interview, and record review, the facility failed to store foods safely and sanitary manner to prevent food borne illnesses, for the 22 residents of the facility, in two of two resident kitchens.

Inspectors wroteThe facility reported a census of 22 residents. Based on interview and record review, the facility failed to submit complete and accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ) when the facility failed to submit staffing hourly data for all nursing personnel by the required deadline.

Inspectors wroteThe facility had a census of 22 residents the sample included 12 residents. Based on observation, record review, and interview, the facility's Quality Assessment and Assurance Program failed to provide good faith efforts to identify multiple issue of concern for 22 residents residing in the facility.

Inspectors wroteThe facility reported a census of 22 residents. Based on interviews the facility failed to provide a safe and sanitary environment by the failure to use appropriate disinfectant to sanitize the washing machines after washing clothes/linens during an outbreak of COVID-19 (highly contagious respiratory virus).

Inspectors wroteThe facility reported a census of 22 with 12 residents in the sample. Based on observation, interviews, and record review the facility failed to complete a base line care plans on four of the new admits into the facility Resident (R) 12, R22, R23, and R127.

Inspectors wroteThe facility had a census of 22 residents with 12 residents included in the sample. Based on observation, interview, and record review, the facility failed to provide scheduled activities to prevent boredom and impaired psychosocial well-being for the residents that were confused and wandered in the facility.

Inspectors wroteThe facility reported a census of 22 residents with 12 residents included in the sample. Based on observation, interview, and record review, the facility failed to develop a comprehensive care plan for Resident (R) 18 related to interventions on the care plan related to a fracture of the Left elbow and Left wrist.

Inspectors wroteThe facility reported a census of 22 with 12 residents included in the sample that included one resident sampled for respiratory services. Based on observation. Interviews, and record review, the facility failed to obtain written orders regarding the rate of oxygen flow for one Resident (R)23, to receive per nasal cannula (a device used to deliver supplemental oxygen),and lack dates the oxygen tubing had been changed). In addition, the facility failed to label/date R23's oxygen tubing, to prevent adverse reactions from oxygen tubing. Findings Included: - The Physician Orders revealed Resident (R)23 had the following diagnosis that included chronic obstructive pulmonary disease (progressive and irreversible condition characterized by diminished lung capacity and difficulty or discomfort in breathing). [...]

Inspectors wroteThe facility reported a census of 22 with 12 residents included in the sample, that included five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to obtain physician ordered parameters for insulin (hormone that the level of glucose in the blood) and lacked notification to the physician for one Resident (R) 22 when staff held the physician ordered insulin.

Inspectors wroteThe facility census totaled 22 residents. Based on interview and record review, the facility failed to maintain an in-service training program for nurses' aides that was appropriate and effective to ensure the continuing competence of nurse aides. The facility identified five Certified Nurse Assistants (CNA's) had been employed over one year. One of the five CNAs lacked the required 12 hours of in-service training, and one other CNA lacked completed training in abuse, neglect, and exploitation (ANE) to ensure the continuing competence of nurse aides and appropriate care and services to all the residents of the facility.