Good Shepherd Care Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF801Feb 16, 2024

  Based on interview and record review, facility staff failed to designate a person to serve as the Director of Food and Nutrition Services with the appropriate qualifications, when the facility did not employ a qualified dietitian or other clinically qualified nutrition professional full-time. The facility census was 51. 1. Review of the facility's Dining Services Manager Roles and Responsibilities policy, dated 2020, showed the policy directed for the dining services manager to comply with current public health and safety standards in all phases of the department's operation. Review showed the policy did not contain information related to the education and experience requirements for the dining services manager. […]

• No harm, potential for more than minimal, widespreadF812Feb 16, 2024

  Based on observation, interview and record review, facility staff failed to store food in a manner to prevent contamination and outdated used. The facility staff failed to perform hand hygiene as often as necessary using approved techniques to prevent cross-contamination. The facility staff failed to maintain the kitchen floors clean and in good repair to prevent the growth and harborage of bacteria. The facility staff also failed to ensure the ice machine, used to supply ice to residents, drained through an air gap to prevent cross-contamination. The facility census was 51. 1. Review of the facility's Food Storage (Dry, Refrigerated, and Frozen) policy, dated 2020, showed: -Food shall be stored on shelves in a clean, dry area free from contaminants. […]

• No harm, potential for more than minimal, widespreadF812Nov 4, 2022

  Based on observation, interview and record review, the facility staff failed to store food in a manner to prevent potential contamination and out-dated use. Facility staff failed to use food in a first in-first out method when facility staff opened multiple containers of the same food item for use. Facility staff also failed to maintain food storage equipment clean and in good repair. The facility census was 61. 1. Review of the facility's Food Storage (Dry, Refrigerated, and Frozen) policy, dated 2020, showed: -Food shall be stored on shelves in a clean, dry area free from contaminants. Food shall be stored at appropriate temperatures and using appropriate methods to ensure the highest level of food safety. -All food items will be labeled. […]

• No harm, potential for more than minimal, patternF658Feb 16, 2024

  Based on observation, interview, and record review, facility staff failed to complete neurological assessments (evaluation completed by staff for early detection of nervous system damage following head trauma) for four cognitively impaired residents (Resident #11, #36, #39 and #41) after unwitnessed falls. The facility census was 51. 1. Review of the facility's policies showed staff did not provide a post fall policy for cognitively impaired residents. Review of the facility's Neurological Assessment Flow Sheet, showed neurological assessments are to be completed as followed: -Every 15 minutes for four times; -Every 30 minutes for two times; -Every 1 hour for two times; -Every 2 hours for two times; -Every 4 hours for two times; -Every 8 hours for four times. 2. […]

• No harm, potential for more than minimal, patternF700Feb 16, 2024

  Based on observation, interview and record review, facility staff failed to accurately complete entrapment assessments for the use of bed rails for five residents (Resident #3, #6, #7, #27 and #30). The facility census was 51. 1. Review of facility's policies showed staff did not provide a bed rail policy. 2. Review of Resident #3's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 10/05/23, showed staff assessed the resident as: -Cognitively intact; -Required full dependence for bed mobility; -Bed rails not used. […]