Good Shepherd Health and Rehabilitation

In the surveyor’s words

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

• Immediate jeopardy, isolatedF656Nov 17, 2023

  Based on interview, record review, review of the facility policy, and review of the Centers for Medicare and Medicaid Services, Resident Assessment Instrument (RAI) Manual 3.0, it was determined the facility failed to implement the comprehensive person-centered care plan, for one (1) of fourteen (14) sampled residents, (Resident #1). Resident #1's Comprehensive Care Plan (CCP), revealed a focus of Wandering/Elopement and impaired safety awareness, initiated on 12/06/2022, due to the resident's history of pacing up and down hallways, making verbal statements about leaving, and packing up belongings. […]

• Immediate jeopardy, isolatedF689Nov 17, 2023

  Based on observation, interview, record review, review of the facility's policies and investigation, it was determined the facility failed to have an effective system in place to ensure each resident received adequate supervision to prevent elopement for one (1) of four (4) sampled residents (Resident #1). On 12/06/2022, Resident #1 was noted to go to the B wing door and attempt to open the door before being re-directed by staff. On that date, the facility assessed the resident to require the utilization of a code alert (monitoring device) due to exit seeking behaviors. However, on 08/22/2023 at approximately 7:30 PM, Resident #1 participated in church service with a group of church volunteers with no activities' staff or nursing staff to provide oversight of the resident. […]

• Immediate jeopardy, isolatedF835Nov 17, 2023

  Based on interview, record review, review of the facility's policy, and review of the Administrator's Job Description, it was determined the facility's Administration failed to have an effective system in place to ensure resources were effectively utilized to provide care and services related to accidents and supervision for one (1) of fourteen (14) sampled residents (Resident #1). The facility failed to maintain substantial compliance, as repeat deficiencies were identified. During the Abbreviated Survey, with an exit date of 04/20/2023, the facility was cited in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656), and 42 CFR 483.25 Quality of Care; Free of Accident Hazards/Supervision (F689). Additionally, the facility alleged substantial compliance on 06/16/2023. […]

• Immediate jeopardy, isolatedF837Nov 17, 2023

  Based on observation, interview, record review, and review of the facility's policies, it was determined the facility failed to ensure the Governing Body, or designated persons, functioning as a Governing Body, that were legally responsible for establishing and implementing policies regarding the management and operation of the facility, was responsible and accountable for the Quality Assurance Performance Improvement (QAPI) program, related to the facility's repeated deficient practice. Repeat deficiencies were cited in the areas of 42 CFR 483.21 Comprehensive Resident Centered Care Plan (F656) and 42 CFR 483.25 Quality of Care; Free of Accident Hazards/Supervision (F689) on the Abbreviated Standard Surveys with exit date 06/08/2021, 04/20/2023, and 11/17/2023. […]

• Immediate jeopardy, isolatedF865Nov 17, 2023

  Based on observation, interview, record review, review of the facility's policy, and review of the facility's Plans of Correction (PoC) submitted for the 04/20/2023 survey, it was determined the facility failed to have effective processes in place to address systemic failures through regularly scheduled Quality Assurance Performance Improvement (QAPI) meetings. As a result, the facility failed to identify quality of care deficiencies; failed to develop and implement plans of action to correct identified quality of care deficiencies; and failed to ensure standards for quality of care regarding performance improvement measures were sustained. […]