Golden Good Shepherd Home

In the surveyor’s words

From the most serious findings on record at Golden Good Shepherd Home, in the surveyor’s own words.

• Actual harm, isolatedF760Nov 26, 2024

  Based on record review and interview the facility failed to ensure a resident was free of significant medication errors for one of one resident (R4) reviewed for significant medication errors in the sample of 28. These failures resulted in R4 ingesting a toxic amount of medication, experiencing increased lethargy, arrhythmia, sedation, and respiratory depression resulting in R4 requiring emergency department services and intravenous fluids. Findings include: R4's Progress Notes dated [DATE] at 5:25 PM and signed by V2 (Director of Nursing) documents, (R4) received the wrong medication this evening. Doctor and family notified. Vitals obtained and will be monitored closely through the night, (R4) is alert and orientated. No need to go the ER (emergency room ) at this time. […]

• No harm, potential for more than minimal, widespreadF812Nov 26, 2024

  Based on observation, interview and record review, the facility failed to ensure use of an effective sanitation solution and prevent spread of potential contamination to food and food preparation surfaces in the kitchen. This failure has the potential to affect all 35 residents residing in the facility. Findings include: On 11/24/24 at 11:45 AM V7 (Dietary Manager) and V8 (Dietary Cook) were in the kitchen preparing to serve lunch. At this time V8 removed a food thermometer from a storage cup containing other kitchen utensils. V8 then retrieved a folded kitchen cloth from the kitchen's storage closet and soaked the cloth in the kitchen's quaternary (bleach) sanitation bucket. V8 proceeded to wipe down the thermometer and began taking temperatures of hot food on the kitchen's steam table. […]

• No harm, potential for more than minimal, widespreadF881Sep 7, 2023

  Based on interview and record review the facility failed to ensure their infection prevention antibiotic stewardship program addressed prophylactic antibiotic use. This has the potential to affect all 34 residents in the facility. Findings include: An Antibiotic Stewardship Program policy excerpt dated 1/1/2018 instructs, Providers will utilize the Loeb Criteria when considering initiation of antibiotics. An excerpt of this policy dated 12/1/2017 states, At 72 hours after antibiotic initiation or first dose in the facility, each resident will be reassessed for consideration of antibiotic need, duration, appropriateness, and de-escalation potential. Within the Antibiotic Stewardship policy is the Loeb Criteria for determining presence of UTI. […]

• No harm, potential for more than minimal, isolatedF550Nov 26, 2024

  Based on observation, interview, and record review the facility failed to cover a urinary catheter bag with a privacy bag for one of one resident (R21) reviewed for dignity in the sample of 28. Findings include: R21's current computerized medical record, documents R21 was admitted to the facility on [DATE] with diagnoses which included Cerebral Infarction, Hemiplegia and Hemiparesis Following Cerebral Infarction Affecting Right Dominant Side, Chronic kidney Disease, Retention of Urine, Other Specified Disorders of Bladder, and Type 2 Diabetes Mellitus. R21's MDS (Minimum Data Set) assessment dated [DATE] documents a BIMS (Brief Interview for Mental Status) Score of 12/15, indicating (moderate cognitive impairment) and R21 has an indwelling urinary catheter. […]

• No harm, potential for more than minimal, isolatedF558Nov 26, 2024

  Based on observation, interview, and record review the facility failed to ensure the call light was in reach for one resident (R2) out of 12 residents reviewed for call lights in the sample 28. Findings include: R2's Current Medical Record documents that R2 was admitted to the facility on [DATE] with diagnoses that included Dementia, Urinary Tract Infection, Type 2 Diabetes Mellitus, Essential (Primary) Hypertension, Acute and Chronic Respiratory Failure with Hypoxia, Chronic Kidney Disease (stage 3), Neuromuscular Dysfunction of Bladder, and Chronic Obstructive Pulmonary Disease. R2's Minimum Data Set assessment dated [DATE] documents R2 has a BIMS (Brief Interview of Mental Status) of 3 (severe cognitive impairment). On 11/24/24 at 10:10 AM R2 was lying in bed wearing oxygen. […]