Good Shepherd Community Care and Rehabilitation

In the surveyor’s words

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

• Actual harm, isolatedF689Jul 22, 2022

  Based on interview and record review, the facility staff failed to ensure the safety of all residents when staff failed to ensure they followed proper standards of practice, facility policy, and the resident's care plan when one aide attempted to transfer one resident (Resident #1) in the Hoyer lift (a mechanical device with a sling attached to lift and transfer a non-ambulatory resident) with no assistance. This resulted in the resident suffering a fall causing a right femur (the large bone in the leg) fracture. The facility census was 66. The Administrator and Director of Nursing (DON) were notified on 7/22/2022, at 12:40 P.M., of the Past Non-Compliance which occurred on 7/18/2022. […]

• No harm, potential for more than minimal, widespreadF728Mar 6, 2026

  Based on observation, interview, and record review, the facility failed to have a system in place to ensure nurse aides (NA) completed their training, competencies, and testing in a timely manner when eight NAs (NA G, NA H, NA I, NA J, NA K, NA L, NA M, and NA N) failed to complete a state approved certified nursing assistant (CNA) training program, competency evaluation, and certification test within four months of beginning work as an NA. The facility census was 61.Review of the facility policy titled, Nurse Aide Qualifications and Training Requirements, revised September 2011, showed the following:-Nurse aides must undergo a state-approved training program;-Nurse Aide is defined as any individual providing nursing or nursing-related services to residents in our facility who are not a… […]

• No harm, potential for more than minimal, widespreadF812Mar 6, 2026

  Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served in a manner to protect the food from possible contamination when staff failed to keep all storage and food preparation services clean and free of debris, and staff failed to complete proper hand hygiene when touching nonfood contact surfaces. This had the potential to affect all residents who consumed food from the facility kitchen. The facility census was 61.Review showed the facility did not provide policies related to the cleaning of kitchen surfaces, use of hair nets, or hand-washing procedures for kitchen staff. […]

• No harm, potential for more than minimal, widespreadF880Mar 6, 2026

  Based on observation, interview, and record review, the facility failed to follow infection control guidelines related to handwashing, personal protective equipment, utilizing the resident's neighbor's bedside table during a dressing change, and not appropriately cleaning shared wound care supplies after changing pressure wound dressings on two residents (Resident #19 and #60).The facility census was 61. Record review of the manufacturer guidelines provided by the facility for CaviWipes, (the disinfectant wipes) used by the facility to clean shared wound supplies between residents, showed the following:-CaviWipes are environmental protection agency (EPA) registered, non-woven, intermediate-level disinfectant wipes designed for hard, non-porous surfaces;-Use gloves to clean, then disinfect… […]

• No harm, potential for more than minimal, widespreadF812Apr 1, 2024

  Based on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served in a manner to protect the food from possible contamination when staff failed to store food in sealed containers; failed to discard expired and freezer burnt food; failed to ensure vents, windows, and fans were free of dirt and lint; failed to ensure the dishwasher washed and rinsed the dishes at the recommended temperature; and failed to ensure the dishwasher chemicals tested at recommended level. This had the potential to affect all residents who consumed food from the facility kitchen. The facility had a census of 62 residents. 1. […]